Workers’ Comp Claims Specialist II

Blue Cross Blue Shield of Michigan; Northern (KY); Hybrid; USD 57,000 - 95,000; Full time

Job summary

AF Group is seeking Claim Representatives I–III to verify coverage, determine compensability, and settle claims within authorized discretion. The role covers medical and indemnity benefits, with increasing discretion across levels.

Includes detailed investigations, reserving, subrogation considerations, medical bill management, and collaboration with managers on complex files. Emphasis on regulatory knowledge and stakeholder communication.

Qualifications

• Bachelor’s degree in a related field; education may be substituted with experience.
• Claim Rep I: at least 1 year workers’ comp claims experience; bilingual skills preferred.
• Claim Rep II: 3 years in workers’ comp claims; multi-jurisdiction experience preferred; bilingual skills preferred.
• Claim Rep III: 5 years in workers’ comp claims; high-touch or complex claims; bilingual preferred.

Responsibilities

• Verifies workers’ compensation coverage of employers and injured employees.
• Determines compensability under workers’ compensation by investigating.
• Determines causal relationship between injury and incident.
• Facilitates return to work for the injured employee.
• Establishes timely reserves based on claim profile.
• Documents specifics of claims with subrogation potential.
• Manages medical bills for non-indemnity and indemnity claims.
• Concludes and closes files after resolution of claims.
• Negotiates settlements within authority.
• Works with manager on complex files.
• Manages outside vendors to contain costs.
• Maintains effective relationships with customers.
• Stays abreast of changes in workers’ compensation statutes.
• Administers complex claims and catastrophic exposures.
• Independent judgment to settle cases prior to mediation or litigation.
• Agent/client relationship management involvement.
• Mentors team members.
• Audits of claim files.
• Back up for team leader.
• Coordinates special projects.

Skills

Computer skills

Medical terminology

Workers' comp laws

Communication skills

Customer service

Negotiation

Multitasking

Independent work

Education

Bachelor’s degree

Job description

AF Group is seeking Claim Representatives I–III to verify coverage, determine compensability, and settle claims within authorized discretion. The role covers medical and indemnity benefits, with increasing discretion across levels.

Includes detailed investigations, reserving, subrogation considerations, medical bill management, and collaboration with managers on complex files. Emphasis on regulatory knowledge and stakeholder communication.