SUMMARY:
Responsible for taking a team leadership role by mentoring less experienced claim representatives while being able to handle own claims with very little supervision in verifying workers' compensation coverage of employer and injured employee against appropriate sources, investigating compensability and the medical causal relationship to ensure proper payment of eligible claims. In addition, responsible for negotiating worker's compensation cases up to assigned authority levels, comprehensive evaluation of cases exceeding authority level, and validating medical bills associated with accidents. Represents CompWest at administrative hearings, bulk settlement conferences or conferences with state regulatory agencies and/or conferences with defense attorneys. Responsible for managing customer service on assigned accounts.
RESPONSIBILITIES/TASKS:
* Verifies workers' compensation coverage of employers and injured employees.
* Determines compensability under workers' compensation by a thorough investigation of the claim.
* Determines the causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
* Facilitates return to work for the injured employee.
* Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
* Documents specifics of claims with potential for subrogation recovery, including the amount of potential recovery monies.
* Manages medical bills for non-indemnity and indemnity claims directly associated with the claimed injury. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
* Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
* Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
* Works closely with manager on complex files or files above settlement/reserve authority.
* Manages outside vendors to ensure cost containment efforts.
* Establishes and maintains effective working relationships with all internal and external customers.
* Stays abreast of changes in workers' compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.
* Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
* Exercises independent judgment to settle cases prior to mediation or litigation.
* Actively participates in agent/client relationship management.
* Assists in mentoring team members.
* Mentors team members.
* Conducts audits of claim files.
* Acts as a backup for team leader.
* Coordinates special projects.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
EMPLOYMENT QUALIFICATIONS
EDUCATION OR EQUIVALENT EXPERIENCE:
Bachelor's degree in a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
EXPERIENCE:
Five years' experience in a workers' compensation claims environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing complex workers' compensation claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred.
OR
Two years of AF Group Claims Representative II experience that includes discretion in determining compensability of complex claims and/or handling complex, high touch or labor intensive customers.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
* Ability and proficiency in the use of computers and company standard software specific to position.
* Knowledge of medical and legal terminology related to the work.
* Knowledge of workers' compensation laws and regulations, including jurisdictional laws.
* Effective oral and written communication skills.
* Effective customer service skills.
* Ability to negotiate, build consensus and resolve conflict.
* Ability to manage multiple priorities and meet established deadlines.
* Attention to detail and analytical skills.
* Ability to work independently as well as within a team.
* Ability to make independent decisions.
* Ability to solve complex problems.
* Ability to train and mentor others.
WORKING CONDITIONS:
Work is performed in an office setting with no unusual hazards. Minimal travel required.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.
