Claims Representative - Workers Compensation

Job Description

• The Claims Representative – Workers Compensation is responsible for processing low-level workers compensation claims, determining compensability and benefits due, and managing claims through resolution.
• This role includes administering action plans, approving payments, maintaining documentation compliance, and ensuring effective communication with claimants and clients.

• Process low-level workers compensation claims, determining compensability and benefits due on long-term indemnity claims.
• Monitor reserve accuracy and file necessary documentation with state agencies.
• Develop and coordinate claim action plans through resolution and return-to-work efforts.
• Approve and process assigned claims in accordance with claim or client contracts.
• Administer subrogation claims and negotiate settlements.
• Communicate claim actions and updates with claimants and clients.
• Ensure claim files are properly documented and coding is accurate.
• Process low-level lifetime medical and/or defined-period medical claims, including required state and physician filings.
• Review and make decisions on treatment recommendations based on utilization review.
• Maintain professional client relationships.
• Support the organization’s quality programs and perform additional duties as assigned.
• Travel as required.

• Minimum of two (2) years of claims management experience or equivalent combination of education and experience.
• Successful completion of Claims Representative training program (if applicable).
• Strong knowledge of workers compensation processes and regulations.
• PC proficiency including Microsoft Office products.
• Strong analytical, interpretive, and organizational skills.
• Excellent written and verbal communication skills.
• Ability to work in a team environment and meet service expectations.

• Bachelor’s degree from an accredited college or university.
• Knowledge of regulations, offsets and deductions, disability duration, medical management practices, and Social Security and Medicare procedures related to workers compensation.

• Claims processing and administration.
• Settlement negotiation.
• Documentation and compliance management.
• Customer service and relationship management.
• Time management and multitasking abilities.

• Bachelor’s degree preferred.
• Equivalent work experience will be considered.