Workers Compensation Claims Representative I
Job Posting for Workers Compensation Claims Representative I at AMERIND
Position Characteristics and Competencies
Problem-solving and analytical thinking
- Strong verbal and written communication skills
- Interest in discovering and developing new ideas
- Service and people oriented
- Agile and adaptable in decision making
- Transparent and interactive in projects and reporting
- Trustworthy as a company rep; forthcoming, communicative, and people-oriented
Job Summary
Incumbent handles Tribal Workers’ Compensation claims. Responsible for all technical aspects of claim management for assigned files including compliance with the AMERIND Risk Benefit Endorsement, Tribal Ordinances (when applicable) and all established performance guidelines. Caseload will consist of medical only claims and less complicated loss time claims. Should also have familiarity with general claims handling software. This individual demonstrates positive and professional relationships with Members, Brokers, and clients.
This job description does not represent an inclusive list of all duties encompassed in this position.
Job Responsibilities
- Interacts with customers and associates over the telephone, in person, and in written correspondence to establish and improve communication and service capabilities.
- Properly investigates and handles workers’ compensation files including medical only claims and less complicated loss time claims within predetermined claim-handling guidelines.
- Takes initial calls and provides instructions on claim filing requirements.
- Initiates return-to-work discussions with the employer and effect return-to-work for the injured worker on lost time claims.
- Interviews claimants, specialists, witnesses, physician or other professionals as necessary.
- Determines compensability and total value of claim; negotiate settlements and make recommendations regarding litigation.
- Establishes timely and appropriate case reserves.
- Investigates and manage subrogation and negotiate settlements.
- Interacts and consults with attorneys and other providers regarding claims to control costs and assist in making decisions and actions.
- Negotiates directly with the claimants as necessary.
- Uses automated diary system to issue indemnity benefits and provide claim management.
- Accurately calculates and pays wage loss and other benefits on lost time claims.
- Reviews and follows up on claims as needed, and closes files as appropriate.
- Documents all action plans and evaluations for claim resolution.
- Maintains organized electronic files.
- Addresses customer complaints and inquiries in an exemplary and professional manner.
- Achieves specific performance outcomes related to quality and quantity of work as established by management.
- Provides cost containment for individual claim and overall claim costs for account to achieve account profitability.
- Conducts in person claim reviews when scheduled or requested.
- Performs the duties noted in the position descriptions in accordance with AMERIND Risk WC Claim Handling Guidelines.
- Performs a wide variety of typing assignments which are sometimes confidential in nature; operates personal computer to enter data, draft, edit, revise, and print letters, tables, reports, and other materials.
- Maintains confidentiality of all information.
- Participates in cross-functional team process improvement projects.
- Performs other duties as assigned.
Supervision of Others
N/A
Minimum Qualifications
- Associate’s Degree in Insurance, Economics, Business Administration or related field
- Bachelor’s Degree in Insurance, Economics, Business Administration or related field preferred
- Two years basic insurance knowledge required
- Prior workers’ compensation claims handling experience preferred
- Valid Driver’s License
- Must be able to successfully pass a background investigation
Additional Eligibility Requirements
- New employees must complete the Associate in Insurance (AINS) designation within six months from the end of the 90-day evaluation period to be eligible for advancement and incentive compensation.
- For continued employment, employees must complete an elective course and six hours of professional development within 12 months after the end of the 90-day evaluation period.
Knowledge/Skills/Abilities
- Demonstrated working knowledge of workers’ compensation administration rules/laws and/or Tribal Work Comp experience preferred.
- Familiarity of technology infrastructure and user of technology tools
- Knowledge of medical and insurance terminology, and of claims processing practices.
- Ability to communicate effectively in the English language, both verbally and in writing.
- Ability to analyze situations and adopt appropriate courses of action.
- Ability to work effectively under stressful conditions.
- Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds, employees and officials.
- Ability to develop and interpret policies, procedures, and regulations.
- Ability to maintain an accurate and organized filing system of complex insurance records and reports.
- Ability to handle multiple tasks and meet deadlines.
- Ability to exercise independent judgment.
- Ability to train and present information to others.
- Ability to speak and present in claim reviews.
- Ability to follow oral and written instruction.
- Ability to collect and analyze data, and prepare and present accurate reports and recommendations.
- Skill in performing statistical and mathematical computations.
- Skill in preparing, presenting, reviewing, and analyzing insurance claims, forms, and reports.
- Skill in providing excellent customer service.
- Skill in operating business computer and office machines, including in a Windows environment, specifically Word, Excel, Access, and presentation software (such as PowerPoint).
- Database management skills.
- Excellent telephone communication skills.
Working Conditions & Physical Demands
- Typical business office setting with moderate noise level.
- Non-office environment may be encountered for offsite presentations and support of company activities.
- Must be able to sit for work at a computer and phone for more than 6 hours per day.
- Must be able to speak clearly.
- Must be able to use hands for dexterity of motion.
- Frequently required to stand, walk and reach with hands and arms.
- Must have ability to occasionally lift 20 lbs.
- Must be willing to travel as necessary which may require overnight stays.
Physical Exam
Employee is required to successfully pass an annual physical exam to certify that the incumbent is capable of performing the physical demands of the job as described above.
Salary.com Estimation for Workers Compensation Claims Representative I in Santa Ana, NM
$69,577 to $86,443
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