Claim Representative I - WI

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

Job summary

AF Group in Wisconsin is seeking an entry-level professional to handle workers' compensation claims for medical and indemnity benefits. The role involves investigating, determining compensability, establishing reserves, negotiating settlements, coordinating with medical providers and attorneys, and ensuring compliance with state law.

This position emphasizes accuracy, timely processing, and collaboration with management on complex files.

Qualifications

• Bachelor’s degree in a related field or equivalent combination of education and experience.
• One year of relevant experience or completion of claims trainee program.
• Certification or progress toward certification is highly preferred and encouraged.

Responsibilities

• Verify workers' compensation coverage of employers and injured employees.
• Determine compensability under workers' compensation by thorough investigation of the claim.
• Determine causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
• Facilitate return to work for the injured employee.
• Establish timely and appropriate reserves based on the profile of the claim within given authority.
• Document specifics of claims with potential for subrogation recovery.
• Manage medical bills for non-indemnity and indemnity claims.
• Approve payment based on knowledge of treatment plan and relationship to injury.
• Conclude and close files after resolution to meet performance standards and comply with state laws.
• Negotiate settlements within authority at earliest possible point.
• Collaborate with manager on complex files.
• Manage outside vendors to contain costs.
• Maintain relationships with internal and external customers.

Skills

Computer literacy

Medical terminology

Negotiation

Communication

Time management

Education

Bachelor's degree in a related field

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.