Senior Claim Representative I
AF Group

Richmond, Virginia

Posted in IT


This job has expired.

Job Info


SUMMARY:

Claim Representative III:

This is the advanced level of the claim handler career path. Investigates claims and exercises significant discretion in the determination of compensability of claims. May handle large, more complex customers requiring high touch, labor intensive claim service. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority. Mentors lower level claim handlers. Coordinates special projects and provides guidance to others.

RESPONSIBILITIES/TASKS:

  • Verifies workers' compensation coverage of employers and injured employees.
  • Determines compensability under workers' compensation by thorough investigation of the claim.
  • Determines 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 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.
ADDITIONAL RESPONSIBILITIES/TASKS:
  • 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 back up for team leader.
  • Coordinates special projects.
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.
ADDITIONAL SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
  • Ability to make independent decisions.
  • Ability to solve complex problems.
  • Ability to train and mentor others.
Senior Claim Representative

This position serves as a technical expert in the claim handler career path. Under limited supervision, handles claims with litigation, complex/catastrophic and/or coverage elements. Handles the most unique cases, where little precedence has been established. May handle the most complex, high touch or labor intensive customers. Serves as a department leader by developing other employees and may function as acting manager in the absence of department management.

RESPONSIBILITIES/TASKS:
  • Independently administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
  • Establishes timely and appropriate reserves based on claim profile and anticipated financial exposure.
  • Represents the Company by working closely with customers, agents and brokers to resolve the most complex claim issues.
  • Negotiates settlements with attorneys or injured and exercises independent judgment to settle cases prior to mediation or litigation.
  • 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.
  • Actively participates in agent/client relationship management.
  • Mentors team members.
  • May serve as department leader in the absence of management or act as manager designee.
  • Leads catastrophic claim events with large claim volume.
  • Handles the most unique cases, where little precedence has been established, requiring innovative administration and problem resolution.
  • Acts as liaison to claim consultants as needed to support enterprise initiatives.
  • May provide oversight to vendors.
  • May take lead role in claim projects or initiatives.
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:

Seven years of progressively more responsible experience in a workers' compensation claims environment that provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing the most complex workers' compensation claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred.

OR

Two years of AF Group Claims Representative III experience that includes independent handling of the most complex claims and/or the most 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 act as a representative of the Company and establish effective working relationships.
  • Ability to manage multiple priorities and meet established deadlines.
  • Attention to detail and analytical skills.
  • Ability to make independent decisions.
  • Ability to solve highly complex problems.
  • Ability to train and mentor others.
  • Ability to lead 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.


This job has expired.

More IT jobs


American Cybersystems, Inc.
Albany, New York
$57.69 - $72.11 per hour
Posted about 2 hours ago

American Cybersystems, Inc.
Holly Springs, North Carolina
$30.00 - $33.00 per hour
Posted about 2 hours ago

American Cybersystems, Inc.
Charlotte, North Carolina
$33.00 - $36.00 per hour
Posted about 2 hours ago

Get Hired Faster

Subscribe to job alerts and upload your resume!

*By registering with our site, you agree to our
Terms and Privacy Policy.