Claim Representative II

Blue Cross Blue Shield of Michigan; Lansing (MI); On-site; USD 57,000 - 95,000; Full time

Job summary

AF Group in the United States is seeking an intermediate level claim handler to manage moderate to difficult workers’ compensation claims with discretion on compensability determinations and reserves. This role emphasizes accuracy, timely settlements, and collaboration with clients and attorneys.

Responsibilities include verifying coverage, investigating claims, establishing reserves, and negotiating settlements within authority, while mentoring teammates and maintaining relationships with

Qualifications

• Bachelor’s degree in a related field is required and continuous learning is encouraged.
• Three years of workers’ compensation claims experience; multi-jurisdiction experience preferred.
• Bilingual skills preferred.
• Certification or progress toward certification is highly preferred.

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.
• Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.

Skills

Communication skills

Customer service

Negotiation

Multitasking

Attention to detail

Education

Bachelor’s degree in a related field

Certification or progress toward certification

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 intermediate level of the claim handler career path. Handles moderate to difficult claims. Exercises progressively more discretion in the determination of compensability of claims. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority.

Compensation

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

Overview

This is the intermediate level of the claim handler career path. Handles moderate to difficult claims. Exercises progressively more discretion in the determination of compensability of claims. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority.

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 the 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 $56,700 and $94,900.

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 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.
• Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
• Exercises independent judgment to settle cases prior to mediation or litigation.
• Actively participates in agent/client relationship management.
• Assists in mentoring team members.

Requirements

Education

Bachelor’s degree in a related field. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.

Experience

Three (3) years of experience in a workers’ compensation claims environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing workers’ compensation claims. Experience of handling claims in multiple jurisdictions preferred. Bilingual skills preferred.

Skills

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.

Knowledge

Ability and proficiency in the use of computers and company standard software specific to position. Knowledge of medical and legal terminology related to work. Knowledge of workers’ compensation laws and regulations, including jurisdictional laws.

EDUCATION AND EXPERIENCE

Relevant combination of education and experience may be considered in lieu of degree.

• Bachelor’s degree in a related field. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
• Three (3) years of experience in a workers’ compensation claims environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing workers’ compensation claims. Experience of handling claims in multiple jurisdictions preferred. Bilingual skills preferred.
• OR
• One (1) year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

OTHER SKILLS AND ABILITIES

• Ability and proficiency in the use of computers and company standard software specific to position.
• Knowledge of medical and legal terminology related to 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.
• Ability to make independent decisions.
• Ability to solve complex problems.