WC Claim Representative III - CA experience required (Remote)

Blue Cross Blue Shield of Michigan; California; Hybrid; USD 65,000 - 109,000; Full time

Job summary

AF Group in the United States is seeking an advanced claim handler with significant discretion in determining compensability. The role involves investigation, reserving, settlement, and mentoring other handlers. Requires California experience and the ability to manage high-complexity files.

You will collaborate with managers on complex cases, coordinate with outside vendors, and stay current on workers’ compensation laws and practices to ensure accurate claims resolution.

Qualifications

• Bachelor’s degree in a related field required.
• Five years of workers’ compensation claims experience including complex claims.
• Two years of AF Group Claims Representative II experience with discretion.

Responsibilities

• Verifies workers’ compensation coverage of employers and injured employees.
• Determines compensability under workers’ compensation by thorough investigation.
• Determines causal relationship between the injury and incident for payment.
• Facilitates return to work for the injured employee.
• Establishes timely reserves based on claim profile within authority.
• Documents details of claims with potential for subrogation.
• Manages medical bills for indemnity and non-indemnity claims.
• Negotiates settlements within authority to final disposition.
• Audits claim files and mentors team members.
• Acts as backup for team leader and coordinates special projects.

Skills

Negotiation

Communication

Multitasking

Attention to detail

Analytical skills

Independence

Teamwork

Decision making

Problem solving

Mentoring

Education

Bachelor’s degree in a related field

Certification encouraged

Job description

SUMMARY

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. Must have California experience.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Verifies workers’ compensation coverage of employers and injured employees.
2. Determines compensability under workers’ compensation by thorough investigation of the claim.
3. Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
4. Facilitates return to work for the injured employee.
5. Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
6. Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
7. 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.
8. Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
9. Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
10. Works closely with manager on complex files or files above settlement/reserve authority.
11. Manages outside vendors to ensure cost containment efforts.
12. Establishes and maintains effective working relationships with all internal and external customers.
13. Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.
14. Mentors team members.
15. Conducts audits of claim files.
16. Acts as a backup for team leader.
17. Coordinates special projects.

EDUCATION AND EXPERIENCE

1. Relevant combination of education and experience may be considered in lieu of degree.
2. 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.
3. Five (5) 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 complex workers’ compensation claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred.
4. Two (2) 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.

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

1. Ability and proficiency in the use of computers and company standard software specific to position.
2. Knowledge of medical and legal terminology related to work.
3. Knowledge of workers’ compensation laws and regulations, including jurisdictional laws.
4. Effective oral and written communication skills.
5. Effective customer service skills.
6. Ability to negotiate, build consensus and resolve conflict.
7. Ability to manage multiple priorities and meet established deadlines.
8. Attention to detail and analytical skills.
9. Ability to work independently as well as within a team.
10. Ability to make independent decisions.
11. Ability to solve complex problems.
12. Ability to train and mentor others.

ADDITIONAL INFORMATION

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.

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 $64,900 and $108,700.

We are an Equal Opportunity Employer. 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.