Under the direction of the Claims Team Leader, the Senior Workers’ Compensation Claim Representative investigates, evaluates, and resolves claims in a timely, fair, and consistent manner, in accordance with established best practices and applicable policy provisions.
Duties may include, but are not limited to:
- Receive and manage new claim assignments.
- Review claim and policy information to establish the basis for investigation and determine the extent of the policy’s obligation to the insured, depending on the line of business.
- Contact, interview, and obtain statements, recorded or in person, from insureds, claimants, witnesses, physicians, attorneys, police officers, and others to gather relevant claim information.
- Arrange surveys and expert evaluations, as appropriate.
- Evaluate facts obtained through investigation to determine liability, if any, and the company’s obligation to the insured under the policy contract.
- Prepare reports related to investigations, settlements, claim denials, and evaluations of involved parties.
- Set reserves within authority limits and recommend reserve changes to the Team Leader.
- Review claim progress and status with the Team Leader and discuss issues and recommended corrective actions.
- Manage litigation files in a timely and appropriate manner.
- Assist the Team Leader in developing methods and process improvements for claims handling.
- Resolve claims in a timely and fair manner.
- Obtain releases, proofs of loss, or compensation agreements and issue company drafts for claim and expense payments.
- Inform claimants, insureds, customers, agents, or attorneys of claim denials when applicable.
- Assist the Team Leader and company attorneys in preparing cases for trial by arranging witness attendance and taking statements, while continuing efforts to resolve claims before trial.
- Refer claims to subrogation, as appropriate.
- Participate in claim file reviews and audits with customers, insureds, and brokers, as needed.
- Administer benefits in a timely and appropriate manner and maintain control of the claim resolution process to help minimize current exposure and future risk.
- Establish and maintain effective working relationships with agents, underwriters, insureds, experts, and other stakeholders.
Depending on the line of business, other duties may include:
- Maintaining system logs
- Investigating compensability and benefit entitlement
- Reviewing and approving medical bill payments or forwarding them for outside review, as necessary
- Managing vocational rehabilitation
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