WC Claim Representative II - CA experience required

AF Group; Dallas (TX); A distancia; USD 57.000 - 95.000; Jornada completa

Descripción de la vacante

AF Group is seeking an intermediate level claim handler for workers' compensation claims. The role handles moderate to difficult claims, exercises discretion in determinations, and negotiates settlements within authority while maintaining reserves and compliance.

Remote-based in the US with California jurisdiction experience required. Candidates should possess a Bachelor's degree and relevant claims experience, with bilingual skills a plus.

Formación

• Bachelor's degree in a related field is required or equivalent combination of education/experience.
• Certification or progress toward certification is highly preferred and encouraged.
• Continuous learning as defined by company philosophy is required.

Responsabilidades

• Verifies workers' compensation coverage.
• Determines compensability by thorough investigation.
• Assesses causal relationship to ensure correct benefits.
• Facilitates return to work for injured employees.
• Establishes reserves within authority based on anticipated exposure.
• Documents potential subrogation recoveries.
• Manages medical bills for all related claims.
• Approves payments per treatment plan.

Conocimientos

Computer skills

Medical terminology

Workers' comp laws

Communication skills

Negotiation

Time management

Attention to detail

Independent decision making

Problem solving

Educación

Bachelor's degree in a related field

Herramientas

MS Office

Claims software

Descripción del empleo

SUMMARY

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. Jurisdiction and experience working claims in California is required but residency in the State of California is not required as this position is remote based in the US.

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.
• 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.
• Other relevant essential functions may be required.

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.

EXPERIENCE

• Claim Representative II: 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 handling claims in multiple jurisdictions preferred. Bilingual skills preferred.
• OR One year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.

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

WORKING CONDITIONS

Work is performed in an office setting or remote 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 $94,900.

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.