Claim Representative II - NV/CA experience required

AF Group; Las Vegas (NV); On-site; USD 57,000 - 95,000; Full time

Job summary

AF Group in Las Vegas seeks a Claim Representative II to handle intermediate-level workers' compensation claims, with CA/NV experience. You will verify coverage, assess compensability, and determine causal relationships to ensure proper benefit payments.

The role requires returning injured employees to work, setting reserves, and negotiating settlements within authority. Collaboration with managers and outside vendors is essential to manage costs and comply with state laws.

Qualifications

• Three years of workers' compensation claims experience.
• Experience handling claims across multiple jurisdictions preferred.
• Bilingual skills preferred.
• One year of AF Group Claims Representative I experience.

Responsibilities

• Verifies workers' compensation coverage.
• Determines claim compensability after investigation.
• Assesses causal relationship to ensure proper benefits.
• Facilitates return to work for the injured employee.
• Establishes reserves within authority based on risk.
• Manages medical bills for related claims.
• Negotiates settlements with attorneys within authority.
• Coordinates with vendors to control costs.
• Maintains relationships with internal and external customers.
• Stays updated on workers' comp laws.

Skills

Independent decision making

Problem solving

Bilingual abilities

Job description

SUMMARY

Claim Representative II: This is the intermediate level of the claim handler career path. Handles moderate 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. Must have CA/NV experience.

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.
• Facilitate 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 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.

ADDITIONAL RESPONSIBILITIES / TASKS

• 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.

EMPLOYMENT QUALIFICATIONS / EDUCATION OR EQUIVALENT EXPERIENCE

• Three years' 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.
• One year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.

SKILLS / KNOWLEDGE / ABILITIES (SKA) REQUIRED

• Ability to make independent decisions.
• Ability to solve complex problems.

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 $56,700 and $4,900.

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.