Senior Claims Representative

Pinnacol Assurance provides caring workers’ compensation protection to Colorado employers and employees. What you’ll do Work with team members to strategically and proactively manage claims and claim‑related issues, provide quality customer service, identify complex claims, and ensure efficient resolution. Contact stakeholders on incoming claims to investigate circumstances, determine compensability, and address red‑flag issues. Determine compensability per Company best practices, case law, and the Colorado Workers’ Compensation Act. Proactively manage open claims, including medical, disability, and litigation management, and investigate adverse developments. Coordinate necessary resources for optimal claim management—claims team, leads, owners, underwriters, business directors, legal resources, return‑to‑work consultants, safety consultants, medical case managers, utilization review, MedPay liaison, provider relations, and claims directors. Communicate and correspond with stakeholders—policyholders, injured workers, agents, medical providers, service vendors, attorneys, and regulatory agencies—via phone, email, fax, meetings, and documentation. Facilitate early return to work by coordinating with policyholder and return‑to‑work consultant. Authorize and process benefit payments and file required paperwork with the Colorado DOWC. Evaluate claims for settlement, estimate indemnity benefits, negotiate settlements with counsel or directly with injured workers, and secure DOWC approval. Provide authority for level 1 and 2 CRs to settle claims within senior CR authority; review their evaluations and document authority. Inform policyholders and agents of claim status and significant developments. Review medical information to authorize payments or refer to additional resources per DOWC Rules of Procedure. Set and maintain accurate reserves by reviewing medical records and predicting future costs, updating reserves as circumstances change. Prepare for, attend, and testify at settlement conferences and hearings. Evaluate medical bill referrals for relatedness and appropriateness; authorize payment or deny with proper documentation. Read and analyze medical records and communicate with internal/external resources to manage treatment plans per Company best practices. What you can expect Contact stakeholders as required by Company best practices on incoming claims. Determine compensability per Company best practices, case law, and the Colorado Workers’ Compensation Act. Proactively manage open claims, including expedited and cost‑effective medical case management, disability and litigation management, and investigation of potential adverse claim development. Coordinate and oversee all necessary resources for claim resolution. Communicate with stakeholders across various channels. Facilitate early return to work. Coordinate benefit authorization and payment, file paperwork with the Colorado DOWC. Evaluate claims for settlement, negotiate, and obtain DOWC approval. Provide authority for CRs to settle claims within senior CR authority. Inform policyholders and agents of claim status. Review medical information and provide authorization or referral. Set and maintain accurate reserves. Prepare and testify at settlement conferences. Evaluate medical bill referrals. Read and analyze medical records and communicate treatment plans. Additional Duties Serve as a resource and mentor to Level 1 and Level 2 claims representatives. Serve on projects and committees as requested. Maintain all Senior CR performance standards. Other duties as requested. What you need to be successful A successful candidate will have 3 or more years of experience managing Colorado workers’ compensation claims, a working knowledge of all required computer systems, meet or exceed all CR 2 metrics, and be proficient in resolving indemnity claims in a timely and cost‑efficient manner. Competencies Communication – Strong written and verbal communication skills, ability to communicate effectively at all levels. Customer Focus – Provides a caring customer experience and approaches interactions with empathy. Curiosity – Strong desire to learn and seek out information. Manages conflict – Strategically navigates difficult conversations to find the best outcome. Organization skills – Manages multiple priorities and large workload while meeting deadlines. Strategic thinking – Solves complex problems and proactively manages difficult situations. Negotiation skills – Negotiates with stakeholders to move claims toward resolution. Relationship Building – Builds trust with stakeholders, securing customer loyalty. Work Environment / Physical Activities Regular attendance required. Extensive telephone and computer work in an office environment. Attend marketing visits with agents and/or policyholders as required. Disclaimer This description is not an exhaustive list of all duties, responsibilities or qualifications associated with this job. We can’t do our work without people like you. Our benefits go beyond the basics. You will choose from diverse benefit offerings for medical, dental and vision. We care about each other. A positive, collaborative work environment with hard workers and high performers. We love who you are. Pinnacol is on a journey to embody diversity, equity and inclusion, creating a culture where everyone feels they belong. Take a day (or 20!) off. 20 paid days off in the first full year plus 9 paid holidays. Take care of yourself. Sign up for unique wellness programs, company‑paid fitness facilities and classes. Get your learning on. Promote a learning culture to master current job and develop future skills through on‑site, online and off‑site professional development opportunities. Give back and get paid. Employee volunteer program includes paid time off to volunteer with Colorado nonprofits. Share in our success. Earn a quarterly incentive, up to 12 percent of annual base salary, when team exceeds goals. When we find the right person, we try to put our best foot forward with an offer that excites you. Compensation range is targeted at $80,900‑$85,600 . Final offer amounts may vary. We are committed to reasonable accommodations for applicants with disabilities. To request assistance, email View email address on click.appcast.io. #J-18808-Ljbffr Pinnacol Assurance