Claim Representative I

Blue Cross Blue Shield of Michigan; Northern (KY); Hybrid; USD 48,000 - 81,000; Full time

Job summary

Blue Cross Blue Shield of Michigan is seeking an entry-level claims handler focused on workers’ compensation, handling medical and indemnity benefits with discretion in compensability and reserves. The role involves investigation, profit-conscious settlements, and coordination with managers on complex files.

The candidate should have a related bachelor’s degree and at least one year of relevant experience or a claims trainee program, with bilingual skills preferred.

Qualifications

• Bachelor’s degree in a related field; certification encouraged.
• Minimum one-year relevant experience or completion of claims trainee program; bilingual preferred.
• Knowledge of workers’ compensation laws and regulations.

Responsibilities

• Verify workers’ compensation coverage of employers and injured employees.
• Determine compensability under workers’ compensation by investigation of the claim.
• Determine causal relationship between injury and incident to ensure proper payment.
• Facilitate return to work for the injured employee.
• Establish timely reserves within authority based on claim profile.
• Document specifics of claims with potential for subrogation recovery.
• Manage medical bills for non-indemnity and indemnity claims related to the injury.
• Conclude and close files after resolution to meet performance standards.
• Negotiate settlements with attorneys or injured parties within authority.
• Collaborate with manager on complex files above settlement/reserve authority.
• Manage outside vendors to support cost containment.
• Maintain effective relationships with internal and external customers.
• Stay updated on workers’ compensation statutes and case law.

Skills

Computer skills

Medical/legal terminology

WC laws

Communication

Customer service

Negotiation

Multitasking

Attention to detail

Teamwork/Independence

Education

Bachelor's degree

Claims trainee program / experience

Job description

SUMMARY:

This is the entry level professional claim handler. Handles medical only and indemnity benefits. Exercises some 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:

• 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.

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

1. 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.
2. Minimum one-year relevant experience that provides the necessary skills, knowledge and abilities or completion of claims trainee program. Bilingual skills preferred.
   

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• 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 consensus and resolve conflict.
• Ability to manage multiple priorities and meet established deadlines.
• Attention to detail and analytical skills.
• Ability to work independently as well as within a team.

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 $48,200 - $80,750.

We are an Equal Opportunity Employer. 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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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.