Workers' Compensation Claims Representative III

Responsibilities

• Manage complex workers' compensation claims involving high financial exposure, sensitive issues, or extended life cycles.
• Investigate coverage and compensability, ensuring thorough documentation and compliance with state statutes.
• Oversee advanced medical case management, including coordination with Nurse Case Managers and external vendors.
• Develop and implement Return-to-Work plans for high-risk claims, collaborating with vocational consultants and legal counsel.
• Identify and investigate potential fraud and subrogation opportunities, partnering with the Special Investigation Unit.
• Establish and maintain accurate claim reserves within authority levels, ensuring timely responsiveness to changing circumstances.
• Evaluate and negotiate settlements within approved authority levels, including structured settlements and Medicare compliance.
• Collaborate with legal counsel to manage litigation and ensure adherence to MEM guidelines.
• Maintain accurate system data and prepare reports for management on high-profile claims.
• Foster cross-departmental collaboration with Underwriting, Premium Consultation, and Loss Prevention.
• Provide mentorship and training to junior adjusters, supporting professional growth and team development.

• High school diploma or equivalent required; bachelor's degree preferred.
• Associate in Claims (AIC) designation preferred.
• Valid driver's license required;
  Texas-All Lines license preferred.
• 3-5 years of claims handling experience, primarily in Workers' Compensation. Missouri experience preferred.

Demonstrates expertise in managing complex Workers' Compensation claims, including advanced medical case management, fraud investigation, and compliance with state statutes. Proficient in developing Return-to-Work plans and collaborating with legal counsel and external vendors.

• Workers' Compensation Claims Management
• Advanced Medical Case Management
• Fraud Investigation Return-to-Work Plan Development
• Claims Handling Experience

• Claims Handling
• Coverage Investigation
• Settlement Negotiation
• Documentation Compliance
• Claim Reserve Management

• Mentorship
• Collaboration
• Communication

• Associate in Claims (AIC)
• Texas-All Lines License

• Workers' Compensation
• Medical Case Management
• Fraud Detection
• Subrogation
• Litigation Management

• Claims Management Systems