WC Claim Representative II - CA

This is the intermediate level of the claim handler career path. Handles moderate to 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.

Jurisdiction and experience working claims in California is required but residency in the State of California is not required as this position is remote based in the US.

• 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.
• Facilitates 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 in order to accurately interpret and apply relevant laws.
• 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.

Bachelor’s degree in a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company’s learning philosophy, is required.

Certification or progress toward certification is highly preferred and encouraged.

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 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.

• Ability and proficiency in the use of computers and company standard software specific to position.
• Knowledge of medical and legal terminology related to the work.
• Knowledge of workers’ compensation laws and regulations, including jurisdictional laws.
• Effective oral and written communication skills.
• Effective customer service skills.
• Ability to negotiate, build…