SUMMARY
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. Must have California experience.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be
assigned.
1. Verifies workers’ compensation coverage of employers and injured
employees.
2. Determines compensability under workers’ compensation by thorough
investigation of the claim.
3. Determines causal relationship between the reported injury and the incident
to ensure appropriate payment of benefits.
4. Facilitates return to work for the injured employee.
5. Establishes timely and appropriate reserves based on the profile of the
claim within given authority based on anticipated financial exposure.
6. Documents specifics of claims with potential for subrogation recovery,
including amount of potential recovery monies.
7. 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.
8. Concludes and closes files following resolution of claims to meet internal
performance standards while complying with state legislation to avoid
penalties and manage expenses.
9. Negotiates settlements with attorneys or injured parties within given
authority at the earliest possible point to bring cases to final
disposition.
10. Works closely with manager on complex files or files above
settlement/reserve authority.
11. Manages outside vendors to ensure cost containment efforts.
12. Establishes and maintains effective working relationships with all internal
and external customers.
13. Stays abreast of changes in workers’ compensation statutes, case law and
rehabilitation efforts/advancements in order to accurately interpret and
apply relevant laws.
14. Mentors team members.
15. Conducts audits of claim files.
16. Acts as a backup for team leader.
17. Coordinates special projects.
EDUCATION AND EXPERIENCE
1. Relevant combination of education and experience may be considered in lieu
of degree.
2. Bachelor’s degree in a related field. Continuous learning, as defined by the
Company’s learning philosophy, is required. Certification or progress toward
certification is highly preferred and encouraged.
3. Five (5) years of 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.
4. Two (2) 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.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each
essential duty satisfactorily. The requirements listed below are representative
of the knowledge, skill, and/or ability required. Reasonable accommodation may
be made to enable individuals with disabilities to perform the essential
functions.
OTHER SKILLS AND ABILITIES
1. Ability and proficiency in the use of computers and company standard
software specific to position.
2. Knowledge of medical and legal terminology related to work.
3. Knowledge of workers’ compensation laws and regulations, including
jurisdictional laws.
4. Effective oral and written communication skills.
5. Effective customer service skills.
6. Ability to negotiate, build consensus and resolve conflict.
7. Ability to manage multiple priorities and meet established deadlines.
8. Attention to detail and analytical skills.
9. Ability to work independently as well as within a team.
10. Ability to make independent decisions.
11. Ability to solve complex problems.
12. Ability to train and mentor others.
ADDITIONAL INFORMATION
The above statements are intended to describe the general nature and level of
work being performed by people assigned to this classification. They are not
intended to be construed as an exhaustive list of all responsibilities, duties
and skills required of personnel so classified. This job description does not
constitute a contract for employment.
WORKING CONDITIONS:
Work is performed in an office setting or remote with no unusual hazards.
Minimal travel required.
PAY RANGE:
Actual compensation decision relies on the consideration of internal equity,
candidate’s skills and professional experience, geographic location, market, and
other potential factors. It is not standard practice for an offer to be at or
near the top of the range, and therefore a reasonable estimate for this role is
between $64,900 and $108,700.
We are an Equal Opportunity Employer. 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.
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