The Claim Associate investigates, evaluates, negotiates, and resolves medical only claims and a limited number of lost time claims within settlement and reserving authority up to stated maximum. (Supervisor will determine actual individual authority up to the stated maximum).
- Communicates with insureds, injured workers, agents, brokers, witnesses, attorneys, loss prevention, and underwriters to obtain and relate necessary information to determine coverage/compensability, facts of loss, and degree of liability/exposure. Maintains contact throughout the life of the file as needed.
- Administers the delivery of timely, appropriate and accurate indemnity and medical benefits.
- Evaluates claim exposure, negotiates and resolves claims. Works closely with defense counsel on litigated cases and attend mediation, arbitration, and hearings, as necessary. Develops litigation plan with defense counsel and track adherence to plan in order to control legal expenses and assure effective resolution.
- Works closely with insureds and employees making visitations and presentations as needed to facilitate partnership approach to claims handling.
- Maintains quality claim files in accordance with best practices, company policy and procedures and state worker’s compensation statutes.
- Implements Managed Care strategies, coordinates rehabilitation or medical management, processes bills, reviews all mail through ImageRight, and monitors progress as appropriate.
- Interacts with State and Federal Boards and Commissions, as appropriate.
- Establishes and maintains proper reserves, as appropriate.
- Keeps up-to-date on State laws and Company procedures relating to various claims as we as educates injured worker and/or insured on same.
- Prepares and presents files for Agent/Broker Reviews and Insured File Review.
- Participates in in-house and outside training programs to keep up-to-date on relevant issues/topics.
- Maintains a working knowledge of all computer systems currently in use.
- Travels throughout States as required for handling claims inventory assigned.
- Continues education in claims through Associate in Claims or Claims Law (AEI) courses.
- Associate’s Degree or one to three years claims handling experience preferred.
- Proficient in Microsoft Office (Word and Excel).
- Must have valid driver’s license.
- Strong attention to detail and strong verbal and written communication skills a must.
- Must be flexible and self-directed with the ability to manage time and other resources wisely.
- Must also have the ability to work effectively with other organizational team members.
- Understand medical terminology and standard medical procedures as they pertain to worker’s compensation, U.S. Longshoreman’s and Jones Act claims.