WC Claim Representative II - CA experience required

AF Group; Sacramento (CA); On-site; USD 57,000 - 95,000; Full time

Job summary

AF Group is seeking Claim Representatives at multiple levels to handle workers' compensation claims, from entry through advanced expertise. Responsibilities include verifying coverage, investigating causality, determining compensability, and coordinating reserves and settlements with growing autonomy.

You will work closely with managers on complex files, mentor junior staff, and ensure timely, compliant adjudication.

Qualifications

• Bachelor's degree or equivalent experience required.
• Experience in workers' compensation claims environment highly preferred.
• Continuous learning as defined by company's philosophy is required.

Responsibilities

• Verifies workers' compensation coverage of employers and injured employees.
• Determines compensability under workers' compensation by thorough investigation.
• Establishes reserves within authority based on claim profile.
• Negotiates settlements with attorneys or injured parties within authority.
• Coordinates with manager on complex files or above settlement/reserve authority.
• Manages medical bills for related claims and ensures payment accuracy.

Skills

Computer skills

Medical terminology

Legal terminology

Workers' compensation laws

Oral communication

Written communication

Customer service

Negotiation

Time management

Attention to detail

Analytical skills

Teamwork

Education

Bachelor's degree

Tools

Company software

Job description

SUMMARY

Claim Representative I: 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.

Claim Representative II: 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.

Claim Representative III: This is the advanced level of the claim handler career path. Investigates claims and exercises significant discretion in the determination of compensability of claims. May handle large, more complex customers requiring high touch, labor intensive claim service. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority. Mentors lower level claim handlers. Coordinates special projects and provides guidance to others.

RESPONSIBILITIES/TASKS

Claim Representative I, II, III: 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.

ADDITIONAL RESPONSIBILITIES/TASKS

Claim Representative II, III: 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.Claim Representative III: Mentors team members. Conducts audits of claim files. Acts as a back up for team leader. Coordinates special projects.This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS

EDUCATION OR EQUIVALENT EXPERIENCE

Claim Representative I, II, III: 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 I: Minimum one year relevant experience that provides the necessary skills, knowledge and abilities or completion of claims trainee program. Bilingual skills preferred.

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.

OROne year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.

Claim Representative III: Five years experience in a workers' compensation claims environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing complex workers' compensation claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred.

ORTwo years of AF Group Claims Representative II experience that includes discretion in determining compensability of complex claims and/or handling complex, high touch or labor intensive customers.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED

Claim Representative I, II, III: 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.

ADDITIONAL SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED

Claim Representative II, III: Ability to make independent decisions. Ability to solve complex problems.

Claim Representative III: Ability to train and mentor others.

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 $94,900.

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.