Claim Representative I - Central

AF Group; New Berlin (WI); On-site; USD 48,000 - 81,000; Full time

Job summary

AF Group is seeking an entry-level professional claim handler for workers' compensation. The role focuses on medical and indemnity benefits, with discretion in compensability decisions and reserving. You will negotiate settlements within authority and support return-to-work initiatives.

Qualifications include a bachelor’s degree, and at least one year of relevant experience or completion of a claims trainee program. Bilingual skills are preferred.

Qualifications

• Bachelor's degree required; related experience may be considered in lieu of degree.
• At least 1 year of relevant experience or completion of a claims trainee program.
• Continuous learning as defined by company policy is required.
• Certification or progress toward certification is preferred.
• Bilingual skills are preferred.

Responsibilities

• Verifies workers' compensation coverage for employers and injured employees.
• Determines compensability through thorough investigation of the claim.
• Assesses causal relationship between injury and incident to ensure proper benefits.
• Facilitates return to work for the injured employee.
• Establishes reserves based on claim profile within authority and anticipated exposure.
• Documents claim specifics including potential subrogation recovery.
• Manages medical bills for non-indemnity and indemnity claims.
• Approves payments based on treatment plans and medical support linked to the injury.
• Closes files after resolution to meet internal standards and comply with state laws.
• Negotiates settlements with attorneys or parties within authority to reach final disposition.
• Collaborates with manager on complex files and those above settlement/reserve authority.
• Manages outside vendors to support cost containment.
• Maintains relationships with internal and external customers.
• Keeps abreast of workers' compensation statutes, case law, and rehab advances.

Skills

Attention to detail

Negotiation

Analytical thinking

Communication skills

Bilingual (preferred)

Education

Bachelor's degree in a related field

Tools

Claims software

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.

EMPLOYMENT QUALIFICATIONS

• 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.
• 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.

Equal Opportunity Employer Statement

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.

Diversity Statement

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.