Claim Representative II

SUMMARY This is the intermediate level of the claim handler career path. Handles moderate to difficult claims. Exercises progressively more discretion in the determination of compensability of claims. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. Verifies workers’ compensation coverage of employers and injured employees. Determines compensability under workers’ compensation by thorough investigation of the claim. Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits. Facilitates return to work for the injured employee. Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure. Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies. 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. Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses. Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition. Works closely with manager on complex files or files above settlement/reserve authority. Manages outside vendors to ensure cost containment efforts. Establishes and maintains effective working relationships with all internal and external customers. Stays abreast of changes in workers’ compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws. Administers complex