Senior Claims Representative

Position 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 workers’ compensation cases up to $100,000 and computing medical bills associated with accidents. Represents United Heartland at administrative hearings or conferences with state regulatory agencies and/or conferences with defense attorneys. . Responsible for managing assigned accounts.

Major Responsibilities:

Verifies workers’ compensation coverage of employer and injured employee from policy information, underwriting, etc. and documents the state the employer is domiciled.
Responsible for customer satisfaction of assigned accounts within region when written premium surpasses $100,000. Responsible for all but minor medical only claims for these accounts, including communication of reserves and other issues with the account.

Investigates compensability to determine whether if employee injury is compensable under workers’ compensation via review of First Report of Injury, contact with employer, employee and corporate and insurance risk management personnel.

Investigates, analyzes and determines the medical causal relationship between employee injury and the accident or activity to ensure the proper payment of claims. Determination is based on information obtained through contact with the employer and employee and/or medical provider, review of medical reports and clarification of medical treatment or medical charges with the provider as they relate to the injury.

Negotiates settlements to workers’ compensation cases, up to $100,000.00, with attorneys, clients or employees.

Collaborates with rehabilitation or medical vendors to expedite an early return to work for the injured employee.

Represents United Heartland at pre-hearings and administrative hearings and conferences with state regulatory agencies. In addition, works with defense attorneys in preparing cases for litigation.

Computes the proper payment for the medical bills and the proper wage replacement benefits for the workers’ compensation indemnity claims directly associated with the accident or activity, ensuring that all payments are made in an accurate and timely manner in compliance with state legislation and internal performance standards.

Investigates workers’ compensation cases to determine possibility of partial or complete subrogation through second injury fund. Presents recommendation to Manager, Claims for review and referral.

Establishes and maintains effective working relationship with rehabilitation and medical vendors and with corporate customers/clients.

Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.

Adheres to the Employee Code of Ethical Conduct and completes additional responsibilities as requested.
REQUIREMENTS
Education:
Bachelor’s degree in Business Administration, Healthcare Administration or related field OR the equivalent in relevant coursework and related experience required.

Experience:
One year previous experience reviewing, investigating, and closing indemnity workers’ compensation claims, including working with attorneys, rehabilitation and medical vendors, and corporate clients.
Thorough working knowledge of workers’ compensation statutes and workers’ compensation filing procedures.

Skills/Abilities:
Proficient in Microsoft Windows.
Demonstrated knowledge of medical terminology.
Effective oral and written communication skills and customer service skills are essential.
Strong interpersonal and negotiation skills and decision-making ability.
Attention to detail and analytical skills required.
Must be able to meet strict deadlines with a high level of accuracy.
Must be able to work independently as well as within a team.