Claims Representative

Apply here: Claims Representative | Dayforce Jobs

Overview

• ·         Investigates, evaluates, and handles assigned claims through final disposition in accordance with company procedures. Investigates coverage and compensability issues.  Handles lost time claims to include medical case management, litigation management, return to work and settlement where necessary.  Uses technology and systems to manage claims, to include document management, utilization review, and pharmacy management.  Develops skillset to pro-actively manage caseload, to include time management, decision makings skills, and having difficult conversations.

Major Areas of accountability

• ·         Investigates assigned claims following sound claim handling techniques in accordance with company claim philosophy and quality assurance standards. 
• ·         Responsible for investigating and determining coverage, compensability, and subrogation potential on every claim, including second injury fund and longshore 8(f) special fund. 
• ·         Determines proper jurisdiction and classifies each claim under state, federal or maritime class codes.
• ·         Establish and adjust reserves or provide reserve recommendations to establish the value of the claim consistent with corporate policies and within assigned authority levels.
• ·         Evaluates and negotiates settlements of claims within assigned authority level.
• ·         Manage all litigation issues arising under assigned claims, to include coverage, compensability, medical causation, return to work issues, and any other issues under the law. 
• ·         Responsible for medical case management, utilization review, return to work, pharmacy management and settlement/mitigation when necessary.
• ·         Continuous communication with injured workers, policyholders, agents, medical providers, plaintiff attorneys and defense attorneys.
• ·         Heightened focus on learning applicable laws, regulations and medical guidelines. 
• ·         Documents claim files with necessary information to confirm all claim issues.  Provides appropriate level of service to agents and policyholders.
• ·         Complies with all customer service standards.  Responds promptly to resolve complaints or claim problems. Manages personal claim caseload effectively and in accordance with productivity and claim cost objectives.
• ·         Performs other job duties as dictated by office circumstances.

Personality/Working Style

Strong character

• o   Alignment with company values, mission, and vision
• o   Trustworthy and honest
• o   Decisive
• o   Curious and persistent
• o   Commitment to accountability         

Passion for innovation

• o   Willingness to learn
• o   Adaptive to changing (tolerance for ambiguity)
• o   Desire to collaborate to achieve corporate goals

Strong communicator

• o   Effective communication skills
• o   Empathetic listener and open-minded
• o   Focus on customer service and stakeholder experience
• o   Effectively handle difficult conversations
• o   Effective use of persuasion

Education Required:

Bachelor’s degree and a minimum of 2 years handling of workers’ compensation claims, or 4 years of experience as an insurance claims adjuster.

OR

High School Diploma/GED with 2 years handling of workers’ compensation claims and 4 years of experience as an insurance claims adjuster.

Skills Required:

Communication, computer literate, math, judgement and problem-solving skills.

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Senior Claims Representative

Apply here: Senior Claims Representative | Dayforce Jobs

Overview

• ·         Investigates, evaluates, and proactively manages assigned claims of variable complexity through final disposition. Investigates coverage and compensability issues.  Handles lost time claims to include high IWIS claims, high exposure claims, as well as claims for assigned special accounts. Will have increased reserve and settlement authority limits. Handling of claims to include medical case management, litigation management, return to work and settlement where necessary. Serves as a resource and mentor to members of the department. Uses technology and systems to manage claims, to include document management, utilization review, and pharmacy management.  Claims assigned will be handled independently under general direction according to the established policies, procedures, and precedents.

Major Areas of Accountability

• ·         Serve as dedicated claims representative to handle special customer service requirements for assigned accounts.
• ·         Proactively manage litigated claims with in-house legal or outside counsel with focus on timely resolution and/or settlement. 
• ·         Evaluate and settle all claims with settlement potential within increased authority limits and present claims exceeding authority levels to executive claims committee for resolution of large exposure claims.
• ·         Responsible for investigating and determining coverage, compensability, and subrogation and second injury fund potential, as well as resolving unique coverage issues where coverage may involve multiple carriers or claims involving employers’ liability exposure.
• ·         Manage occupational disease claims and any other claims involving extraordinary claim issues, to include high IWIS claims and other high exposure claims. 
• ·         Manage personal caseload effectively to mitigate exposure within controllable claim cost objectives.
• ·         Develop cost containment strategies for large claims and make recommendations for productive case outcomes.
• ·         Document claim files in accordance with quality review standards and complete reinsurance reporting on high exposure claims.
• ·         Approach job in a conscientious, mature fashion demonstrating a sense of responsibility.  Exhibit an ethical manner of conduct and keep sensitive information confidential.  Demonstrate a willingness to contribute whatever is necessary to get the job done.
• ·         Investigate larger more complex workers’ compensation claims following sound claims handling techniques in accordance with company claim philosophy and quality assurance standards.
• ·         Establish and maintain appropriate file reserves with increased authority limits that accurately reflect file exposure in accordance with company file reserving procedures.
• ·         In addition to continuous communication with injured workers, medical providers, plaintiff attorneys and defense attorneys, also provides an appropriate level of customer service to policyholders and agents and promptly responds to resolve complaints or claim problems.
• ·         Resource for and mentor to less experienced claims representatives.
• ·         Provides other job duties as dictated by office circumstances.

Personality/Working Style

Strong character

• o   Alignment with company values, mission, and vision
• o   Trustworthy and honest
• o   Decisive
• o   Curious and persistent
• o   Commitment to accountability

Passion for innovation

• o   Willingness to learn
• o   Adaptive to changing (tolerance for ambiguity)
• o   Desire to collaborate to achieve corporate goals

Strong Communicator

• o   Effective communication skills
• o   Ability to navigate difficult conversations
• o   Empathetic listener and open-minded
• o   Focus on customer service and stakeholder experience

Analytical skills

• o   Mathematics/analytical background            
• o   Investigation skills
• o   Negotiation skills
• o   Problem solving skills
• o   Time management skills

Education

Bachelor’s degree and four years handling workers’ compensations claims

OR

High School Diploma/GED with eight years of insurance claims handling experience, four of which being workers’ compensation claims

Experience

Minimum of two years as a Claims Representative strongly preferred

CPCU, ARM, AIC preferred

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Summit is currently hiring a claims representative/workers’ comp claims adjustor. This hybrid role is based in our Baton Rouge, Louisiana, office. If you have a workers’ compensation license, please apply today! https://gaig.wd1.myworkdayjobs.com/Summit_External/job/Baton-Rouge-LA-USA/Claims-Representative--Hybrid-_R6606-1

Essential Job Functions and Responsibilities

• Investigates and maintains claims:
• Reviews and evaluates coverage and/or liability.Secures and analyzes necessary information (i.e., reports, policies, appraisals, releases, statements, records or other documents) in the investigation of claims.
• Works toward the resolution of claims files, and may attend arbitrations, mediations, depositions or trials as necessary.
• May affect settlements/reserves within prescribed limits and submit recommendations to supervisor on cases exceeding personal authority.
• Conveys simple to moderately complex information (coverage, decision, outcomes, etc.) to all appropriate parties, maintaining a professional demeanor in all situations.
• Ensures that claims payments are issued in a timely and accurate manner.
• Ensures that claims handling is conducted in compliance with applicable statues, regulations and other legal requirements, and that all applicable company procedures and policies are followed.
• Performs other duties as assigned.

Job Requirements