索赔代表 II - 南卡罗来纳州
Claim Representative II - South Carolina
SUMMARY
这是索赔处理者职业路径的中级水平。处理中等和复杂的索赔。在确定索赔可赔偿性方面逐步增加自主判断。在确定索赔准备金时考虑多种因素。在授权范围内协商并解决索赔。有南卡罗来纳州工伤补偿经验者优先。
ESSENTIAL DUTIES AND RESPONSIBILITIES 包括以下内容。其他职责可能被指派。
- 验证雇主和受伤员工的工伤补偿保险。
- 通过彻底调查索赔，确定工伤补偿的可赔偿性。
- 确定报告的伤害与事件之间的因果关系，以确保适当支付福利。
- 协助受伤员工重返工作岗位。
- 根据索赔的资料，在授权范围内基于预期财务风险及时且适当地建立准备金。
- 记录具有代位追偿回收潜力的索赔细节，包括潜在回收金额。
- 直接管理与索赔伤害直接相关的非赔偿性和赔偿性医疗账单。根据治疗方案知识和显示治疗与伤害关系的医疗支持，批准付款。
- 在索赔解决后完成并关闭文件，以满足内部绩效标准，同时遵守州法律以避免处罚并控制成本。
- 在授权范围内尽早与律师或受伤方协商和解，使案件最终结案。
- 与经理密切合作处理复杂文件或超出和解/准备金权限的文件。
- 管理外部供应商，以确保成本控制措施。
- 建立并维护与所有内部和外部客户的有效工作关系。
- 关注工伤补偿法规、判例法和康复工作的变化及进展，以便准确解释和应用相关法律。
- 在授权范围内处理复杂索赔和重大风险，包括来自专属大客户的索赔。
- 在调解或诉讼前运用独立判断解决案件。
- 积极参与代理/客户关系管理。
- 协助指导团队成员。
EDUCATION AND EXPERIENCE
教育和经验的相关组合可替代
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SUMMARY
This is the intermediate level of the claim handler career path. Handles moderate and 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. South Carolina workers' compensation experience preferred.
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.
- Facilitate 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 claims and catastrophic exposures within authority, including claims from dedicated large accounts.
- Exercises independent judgment to settle cases prior to mediation or litigation.
- Actively participates in agent/client relationship management.
- Assists in mentoring team members.
EDUCATION AND EXPERIENCE
Relevant combination of education and experience may be considered in lieu of degree.
- Bachelor’s degree in a related field. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
- Three (3) years of experience in a workers’ compensation claims environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing workers’ compensation claims. Experience of handling claims in multiple jurisdictions preferred. Bilingual skills preferred. · OR
- One (1) year of AF Group Claims Representative I experience that includes handling of difficult or complex claims.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
OTHER SKILLS AND ABILITIES
- Ability and proficiency in the use of computers and company standard software specific to position.
- Knowledge of medical and legal terminology related to the work.
- Knowledge of workers’ compensation laws and regulations, including jurisdictional laws.
- Effective oral and written communication skills.
- Effective customer service skills.
- Ability to negotiate, build consensus and resolve conflict.
- Ability to manage multiple priorities and meet established deadlines.
- Attention to detail and analytical skills.
- Ability to work independently as well as within a team.
- Ability to make independent decisions.
- Ability to solve complex problems.
ADDITIONAL INFORMATION
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment
PAY RANGE
Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market, and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $56,700 - $94,900.
We are an Equal Opportunity Employer. We will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.
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Originally posted on Himalayas