Claim Representative II - NV/CA

SUMMARY:   

Claim Representative II: 

This is the intermediate level of the claim handler career path. Handles moderate difficult claims. Exercises progressively more discretion in the determination of compensability of claims. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority. 

RESPONSIBILITIES/TASKS:

Claim Representative Ii:

• Verifies workers’ compensation coverage of employers and injured employees. 

• Determines compensability under workers’ compensation by thorough investigation of the claim.

• Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.

• Facilitate return to work for the injured employee.

• Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.

• Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.

• Manages medical bills for non-indemnity and indemnity claims directly associated with the claimed injury. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury. 

• Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.

• Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.

• Works closely with manager on complex files or files above settlement/reserve authority. 

• Manages outside vendors to ensure cost containment efforts. 

• Establishes and maintains effective working relationships with all internal and external customers. 

• Stays abreast of changes in workers’ compensation statutes, case law, and rehabilitation efforts/advancements to accurately interpret and apply relevant laws.

ADDITIONAL RESPONSIBILITIES/TASKS:

Claim Representative II:

• Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
• Exercises independent judgment to settle cases prior to mediation or litigation.
• Actively participates in agent/client relationship management. 
• Assists in mentoring team members.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS

EDUCATION OR EQUIVALENT EXPERIENCE:

EXPERIENCE:

Claim Representative II:  

Three years’ experience in a workers’ compensation claims environment which provides the necessary skills, knowledge, and abilities, such as experience in reviewing, investigating, and closing workers’ compensation claims. Experience of handling claims in multiple jurisdictions preferred. Bilingual skills preferred.

OR

One year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

Claim Representative II:

• Ability to make independent decisions.
• Ability to solve complex problems. 

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards. Minimal travel required.

PAY RANGE:
Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market, and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $56,700 and $4,900.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge, and ability levels associated with performing the duties and responsibilities contained in this job description. 

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.

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