Claims Representative

Education & Licensing

• Bachelor's degree from an accredited college or university preferred.

Experience

• Two (2) years of claims management experience or equivalent combination of education and experience or successful completion of Claims Representative training required.

Skills & Knowledge

• Developing knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure as applicable to line of business

• Excellent oral and written communication, including presentation skills

• PC literate, including Microsoft Office products

• Analytical and interpretive skills

• Strong organizational skills

• Good interpersonal skills

• Ability to work in a team environment

• Ability to meet or exceed Service Expectations

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Processes low level workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.

• Develops and coordinates low level workers compensation claims' action plans to resolution, return-to-work efforts, and approves claim payments.

• Approves and processes assigned claims, determines benefits due, and administers action plan pursuant to the claim or client contract.

• Administers subrogation of claims and negotiates settlements.

• Communicates claim action with claimant and client.

• Ensures claim files are properly documented and claims coding is correct.

• May process low-level lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.

• Maintains professional client relationships.

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