Claims Representative - Work Comp Claims

Seven Hills, OH

Post Date: 08/02/2018 Job ID: 2527
PRIMARY PURPOSE: To analyze mid and higher-level workers compensation or general liability claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements. 
ESSENTIAL FUNCTIONS and RESPONSIBILITIES: 
  • Manages general liability claims by gathering information to determine liability exposure; assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level.
  • Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
  • Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
  • Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
  • Manages subrogation of claims and negotiates settlements.
  • Communicates claim action with claimant and client. 
  • Ensures claim files are properly documented and claims coding is correct. 
  • Processes complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
  • Maintains professional client relationships. 

ADDITIONAL FUNCTIONS and RESPONSIBILITIES: 
  • Performs other duties as assigned. 
  • Supports the organization's quality program(s)

WORK ENVIRONMENT:

When applicable and appropriate, consideration will be given to reasonable accommodations. Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines 

 

Physical: Computer keyboarding, travel as required 

 

Auditory/Visual: Hearing, vision and talking 

 

NOTE: Credit security clearance, confirmed via a background credit check, is required for this position. The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.
SKILLS & KNOWLEDGE:
  • Knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure as applicable to line of business 
  • Excellent oral and written communication, including presentation skills 
  • PC literate, including Microsoft Office products 
  • Analytical and interpretive skills 
  • Strong organizational skills 
  • Good interpersonal skills 
  • Ability to work in a team environment 
  • Ability to meet or exceed Service Expectations 

EXPERIENCE: Three (3) years of claims management experience or equivalent combination of education and experience or successful completion of Claims Representative training required.


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