Claim Representative I - WI

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

Job summary

AF Group in Wisconsin, USA is recruiting for an entry-level professional claims handler specializing in medical and indemnity benefits. The role requires evaluating compensability, reserves, and settlements within authority, while adhering to state laws and internal standards.

Office-based with minimal travel and strong attention to detail are essential. The compensation and benefits package reflects internal equity, candidate skills, and market factors, with an estimated pay range of $48,200 to

Qualifications

• Bachelor’s degree in a related field. Continuous learning, as defined by the company’s learning philosophy, is required.
• Knowledge of medical and legal terminology related to the work.
• Effective oral and written communication skills.
• Ability to negotiate, build consensus and resolve conflict.

Responsibilities

• 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.

Skills

Bachelor's degree required

Computer literacy

Medical terminology

Negotiation

Communication

Education

Bachelor’s degree in a related field

Tools

Company standard software

Job description

Compensation: Competitive Compensation and Benefits Package

About Us

AF Group’s focused and passionate team uses industry-leading best practices, analytics and resources to manage risk and minimize loss for our policyholders while strengthening businesses with our valued independent agent partners.

We strive to continuously increase the long-term value of our organization by outperforming our industry peers and fostering a culture of underwriting and claims excellence.

This is the entry-level professional claim handler. Handles medical only and indemnity benefits. Exercises some discretion in the determination of compensability of ...

Compensation

Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market, and other ...

Responsibilities

Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage ...

Workers' Compensation

Verifies workers’ compensation coverage of employers and injured employees. Determines compensability under workers’ compensation by thorough investigation of the ...

Claims

Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies. Manages medical bills for ...

Works closely with manager on complex files or files above settlement/reserve authority. Manages outside vendors to ensure cost containment efforts. Establishes and ...

Performance

Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure. Stays abreast of changes ...

Requirements

Education & Experience

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 ...

Knowledge

Ability and proficiency in the use of computers and company standard software specific to position. Knowledge of medical and legal terminology related to ...

Skills

Effective oral and written communication skills. Effective customer service skills. Ability to negotiate, build consensus and resolve conflict. Ability to manage ...

About Us

AF Group’s focused and passionate team uses industry-leading best practices, analytics and resources to manage risk and minimize loss for our policyholders while strengthening businesses with our valued independent agent partners.

We strive to continuously increase the long-term value of our organization by outperforming our industry peers and fostering a culture of underwriting and claims excellence.

AF Group (Lansing, Mich.) and its subsidiaries are a premier provider of innovative insurance solutions. Insurance policies may be issued by any of the following companies within AF Group: Accident Fund Insurance Company of America, Accident Fund National Insurance Company, Accident Fund General Insurance Company, United Wisconsin Insurance Company, Third Coast Insurance Company, or CompWest Insurance Company.

View Summary

Company: AF Group

Location: WI, USA

Level: Non-Manager

Compensation: Competitive Compensation and Benefits Package

JobFamily: Claims Processing

Industry: Insurance Services

Overview

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.

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.

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. Work is performed in an office setting with no unusual hazards. Minimal travel required.

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.

Responsibilities

• 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 maintainseffective workingrelationships with all internal and externalcustomers.
• 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.

• 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 maintainseffective workingrelationships with all internal and externalcustomers.
• 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.

Requirements

• 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 of 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.
• 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.
• 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 of 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.
• 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.

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. Work is performed in an office setting with no unusual hazards. Minimal travel required.