Workers' Compensation Claims Representative III

Jobtailor; Illinois; On-site; USD 70,000 - 110,000; Full time

Job summary

Jobtailor is seeking a skilled Workers' Compensation Claims Specialist in Illinois. You will manage complex WC claims with high exposure, coordinate medical case management, and develop Return-to-Work plans with vocational consultants and legal counsel.

Your role includes fraud detection, subrogation analyses, and collaboration with Underwriting and Loss Prevention to ensure compliant reserves and settlements. Mentoring junior adjusters and preparing management reports are also important.

Qualifications

• High school diploma required; bachelor's degree preferred.
• Associate in Claims (AIC) designation preferred.
• Missouri experience preferred; Texas-All Lines license preferred.

Responsibilities

• Manage complex workers' compensation claims with high exposure and long life cycles.
• Investigate coverage and compensability with compliant documentation.
• Oversee advanced medical case management with Nurse Case Managers and external vendors.
• Develop and implement Return-to-Work plans for high-risk claims with vocational consultants.
• Identify and investigate potential fraud and subrogation opportunities with the SIU.
• Maintain accurate claim reserves within authority levels for timely responses.
• Evaluate and negotiate settlements within authority, including Medicare compliance.
• Collaborate with legal counsel to manage litigation and MEM guidelines.
• Maintain data in systems and prepare reports for management on high-profile claims.
• Foster collaboration with Underwriting, Premium Consultation, and Loss Prevention.
• Provide mentorship and training to junior adjusters.

Skills

Workers' Compensation Claims

Advanced Medical Case Management

Fraud Investigation

Return-to-Work Plan Development

Litigation Management

Subrogation

Settlement Negotiation

Documentation Compliance

Claim Reserve Management

Mentorship

Collaboration

Communication

Education

High school diploma

Bachelor's degree preferred

Associate in Claims (AIC)

Tools

Claims Management Systems

Job description

Responsibilities

• Manage complex workers' compensation claims involving high financial exposure, sensitive issues, or extended life cycles.
• Investigate coverage and compensability, ensuring thorough documentation and compliance with state statutes.
• Oversee advanced medical case management, including coordination with Nurse Case Managers and external vendors.
• Develop and implement Return-to-Work plans for high-risk claims, collaborating with vocational consultants and legal counsel.
• Identify and investigate potential fraud and subrogation opportunities, partnering with the Special Investigation Unit.
• Establish and maintain accurate claim reserves within authority levels, ensuring timely responsiveness to changing circumstances.
• Evaluate and negotiate settlements within approved authority levels, including structured settlements and Medicare compliance.
• Collaborate with legal counsel to manage litigation and ensure adherence to MEM guidelines.
• Maintain accurate system data and prepare reports for management on high-profile claims.
• Foster cross-departmental collaboration with Underwriting, Premium Consultation, and Loss Prevention.
• Provide mentorship and training to junior adjusters, supporting professional growth and team development.

Requirements

• High school diploma or equivalent required; bachelor's degree preferred.
• Associate in Claims (AIC) designation preferred.
• Valid driver's license required; Texas-All Lines license preferred.
• 3-5 years of claims handling experience, primarily in Workers' Compensation. Missouri experience preferred.

Core Competencies

Demonstrates expertise in managing complex Workers' Compensation claims, including advanced medical case management, fraud investigation, and compliance with state statutes. Proficient in developing Return-to-Work plans and collaborating with legal counsel and external vendors.

Highest-signal resume keywords

• Workers' Compensation Claims Management
• Advanced Medical Case Management
• Fraud InvestigationReturn-to-Work Plan Development
• Claims Handling Experience

ATS Optimization Keywords

Hard Skills

• Claims Handling
• Coverage Investigation
• Settlement Negotiation
• Documentation Compliance
• Claim Reserve Management

Soft Skills

• Mentorship
• Collaboration
• Communication

Certifications & Qualifications

• Associate in Claims (AIC)
• Texas-All Lines License

Industry Keywords

• Workers' Compensation
• Medical Case Management
• Fraud Detection
• Subrogation
• Litigation Management

Tools & Technologies

• Claims Management Systems