Senior Claims Representative

Directs and provides legal and compliance services for the company's insurance operations.  Has responsibility for advising management on all aspects of the company's operations which are affected by legal rulings, statutes, decisions of courts and administrative bodies, contracts, and regulations.  Has responsibility for and directs the legal activities of the company, including providing for representation of the company before the insurance department, legislative bodies and in litigation not based on insurance policies.

 

Experience:

5 - 7 years' experience handling workers compensation claims

 

Education:  

Bachelor's degree in Business Administration, Insurance, or closely related field preferred

 

AIC and AIM Certifications preferred

 

Under the general direction of the Claims Manager, investigates, evaluates, negotiates, and settles assigned high exposure, complex claims, following sound claims handling techniques and in accordance with company claims philosophy, statutory requirements and quality assurance standards. Must be able to work independently, with minimal supervision and within assigned authority.

 

Claims Investigations

Investigates assigned claims for coverage, promptly notifying Corporate Claims of any issues, so that MEM's position can be evaluated, and appropriate correspondence issued.  Documents every claim with a coverage analysis notepad.

 

Recognizes and acts upon opportunities when a Face-to-Face visit would provide maximum value to investigate, establish rapport or minimize litigation potential.  Engage Field Service Manager to assist when needed. 

 

Case File Management

Oversees the medical aspects of more complex files (to include catastrophic claims or claims with high severity) to ensure quality care in a cost-effective manner. This includes working with network providers, referring to Utilization Management, engaging Nurse Case Management when appropriate and securing special opinions as needed (such as Specialists, Independent Medical Evaluations, Second Opinions, Functional Capacity Evaluations, Medical Director input, permanent restrictions, and lifetime medical needs).  Reviews and processes medical bills in a timely manner.

 

Documents files with all relevant facts and actions taken, action plan, necessary reports, investigative notes, and other data as may be required by the state Workers' Compensation Law, Federal Longshore and Harbor Workers' Compensation Act, the State Insurance Department and MEM guidelines.

 

Return-to-Work Program

Effectively manages disability via the Return-to-Work Program, which includes securing job descriptions and Policyholder education about the benefits of providing light duty.  Ensures accuracy of disability payments by securing wage statements and correctly calculating rates, which may include securing and analyzing tax information. Ensures benefit payments are timely and in accordance with statutory requirements so that there is no exposure to penalties or interest.

 

Claims Reserves 

Establishes and maintains claim reserves, which in the aggregate are sufficient to discharge ultimate corporate liability.  This requires timely responsiveness to changing claim circumstances, with avoidance of stair-stepping or significant adverse development.  File documentation should be sufficient to explain the rationale for reserve changes.  Secure approval for any reserves beyond stated authority.  Completes Serious Claim Notices according to guidelines.

 

Negotiate Settlements 

Obtains medical disability ratings in accordance with statutory requirements. Evaluates a reasonable settlement range for claim resolution and negotiates settlements (either directly with the Injured Worker or, if represented, with their attorney) within approved authority levels.  

 

Recognizes appropriate opportunities for structured settlements and employs the necessary resources to develop and negotiate this type of settlement.

 

Claims Litigation

Directs attorneys in preparing assigned claims for defense and manages legal throughout claim to final resolution/settlement.  Collaborates with counsel to determine legal plan of action, which may include depositions, medical examinations, and vocational evaluations. Ensures MEM litigation guidelines are followed throughout the process and in review/approval of legal bills submitted. 

 

Recognizes claims with Medicare exposure and works with defense counsel to protect Medicare's interests.  Obtain Medicare Set-Aside Trusts from approved vendors and send claims to Centers for Medicare Services for approval, when appropriate.  Keeps abreast of Medicare changes.

 

Reporting

Provides requested updates to Management on high profile or high dollar claims. 

Prepare and present claims for Corporate Plan of Action meetings and Account Claim Reviews as requested.

 

Customer Care

Provides appropriate level of service to both internal and external customers, communicating claim status to Producers and Policyholders as requested. Complies with standards for service and prompt contacts. Takes prompt action to respond to and resolve complaints and problems.  Assists Policyholders and agents with questions or training needs as requested.

 

Communication

Persuasive Communication

Diagnostic Information Gathering

Analytical Thinking

Results Orientation

Business Acumen

Adaptability

Personal Accountability

 

Workers Compensation

Managed Care Systems

Medical Terminology

Reserving Calculation

Litigation Management

 

Microsoft Office Suite-Intermediate (e.g., excel, PowerPoint, Outlook, Microsoft Word)

Claims Processing Software/Paperless tool (e.g., Image Right)