WC Claims Representative 1

Job Title

Investigates workers' compensation injury/illness claims, documents claim handling, and pays and/or denies benefits in a caseload of primarily medical only (MO) workers' compensation claims. Limited indemnity (disability) claims may be assigned to representatives for training purposes, at supervisor discretion. This position is also responsible for providing support to the claims department.

Responsibilities

Investigate claims for compensability by analyzing claims-related information and applying claim handling guidelines.

Verify active policy/coverage on new claims and determine if claim involves medical benefits only or includes exposure for lost time.

Establish case reserves consistent with exposure on new claims. Examine reserves on a regular basis and adjust reserves if there is a significant change in exposure.

Serve and file state forms when required.

Investigate subrogation issues on claims, and place responsible third parties on notice of our client's subrogation interest. Pursue subrogation or transfer file as appropriate.

Receive and respond to telephone inquiries. This includes but is not limited to contact with injured employees, employers and health care providers.

Authorize payment of bills for reasonable and necessary medical treatment, expenses associated with claims investigations and obtaining records. Send bills and records for audit when appropriate.

Authorize or deny medical benefits within established time frames.

Manage caseload with assistance of computer-operated diary and maintain current diaries.

Participate in on-going training opportunities to remain current on all aspects of claims handling and customer service.

Ensure timely filing of regulatory documents via EDI (Electronic Data Interchange); submit applicable claims to Index Bureau Reporting (ISO) and document files as applicable.

Provide additional levels of management and claim department operational support to include payment review/approval/input and complete scheduled or special project work as needed.

May perform other functions as assigned.

Qualifications

Minimum of two years office experience or post-high school education.

Ability to interpret and evaluate limited medical and limited legal concepts.

Analysis and decision-making skills.

Good to excellent math and analytical ability.

Good oral and written communication skills.

Willing to learn and apply negotiation techniques.

Education

High school diploma or equivalent.

Additional Company Details

The Company is an equal employment opportunity employer. We do not accept any unsolicited resumes from external recruiting firms. The company offers a competitive compensation plan and robust benefits package for full time regular employees. Base salary & Benefits include Health, dental, vision, life, disability, wellness, paid time off, 401(k) and profit-sharing plans. Salary Range: $49,000 - $55,000 The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment.

Additional Requirements

- Occasional Travel

Sponsorship Details

Sponsorship not Offered for this Role