WC Claims Representative Multi-State

WC Claims Representative Multi-State

General Description
The Claims Representative independently adjudicates multi-state medical only and indemnity claims that have
subrogation involvement, where non-catastrophic in nature.

1. Receives medical-only and lost time assignments; distribution 75%/25%. Verifies and determines applicability of
coverage. Completes 24 hour contact with employer, employee and attending physician inclusive of telephonic contact,
recorded statements and/or in person interviews with the insured, employee, physician, and witnesses. Recorded
statements may be required on questionable medical-only occurrences.
2. Reviews all coverage issues and determines compensability within company standards.
3. Aggressively manages all aspects of the workers’ compensation claims management process inclusive of litigation and
providing direction to defense counsel.
4. Responsible for customer relations management, consistently establishing and maintaining high levels of trust and
confidence with clients, through constant contacts, prompt response and resolving client’s questions and claim issues.
5. Responsible for setting of reserves to Ultimate Probable Cost (UPC). Sets reserves for anticipated exposure subject to
authority limits.
6. Addresses timely benefit delivery including production of benefit notices to the injured party as required in the
applicable jurisdiction.
7. Coordinates return to work (RTW) in accordance with the medical/disability plan for the injured worker.
8. Documents files properly in the claims system.
9. Maintain active diary in 30 day intervals
10. Negotiates settlements directly with the injured worker or opposing counsel subject to authority limits.
11. Considers Medicare’s interests related to Conditional payments and injured workers eligibility and settlements.
12. Recognizes and manages 3rd party liability and subrogation through recovery.
13. Reviews medical and expense bills for causal relationship and bill charges over $1500.00.
14. Consults with Claim Supervisor/Claims Manager/Executive claims on files where assistance and consultation are needed.
15. Completion of Claim Status reports.
16. Makes assignments to nurse case management when indicated, monitoring their billing and performance.
17. Coordinate claim review meetings with both internal and external parties.
18. Attend hearings and depositions when required.
19. All other duties as assigned.

COMPETENCIES/QUALIFICATIONS
• Professional telephone demeanor, good verbal and written communication skills, good listening skills, along with strong
organizational skills.
• Thorough knowledge of workers’ compensation claims procedures and policies.
• Possess a strong understanding of human nature and motivation principles.
• Readily control/handle problem issues in times of stress and in a climate of conflict and/or adversity.
• Computer literacy including strong familiarity with Microsoft Office Suite. Ability to type 45 WPM.
• Basic understanding of business technology.
• Responsiveness to changing business needs.
• Ability to work well under pressure and multi-task in a fast paced environment while continually paying attention to detail.
• Ability to adhere to the code of ethical conduct and engage in fair claims settlement practices.
• Ability to take direction and make decisions.
• Ability to learn new procedures quickly and adapt to a changing environment.
• Ability to work in a team environment.
• Ability to work with limited supervision.

EDUCATION/EXPERIENCEREQUIREMENTS
• Minimum Education: Bachelor’s degree and/or 0-1 years similar experience is required.
• Litigation experience is preferred.
• Prefer relevant state licensing or ability to gain licensing is required.