工伤理赔代表 III - 加州
Workers' Comp Claim Representative III - CA
SUMMARY
这是理赔专员职业路径的高级阶段。调查理赔案件，并在确定理赔可赔付性方面行使重要裁量权。可能处理大型、更复杂的客户，需要高接触度、劳动密集型的理赔服务。在确定理赔准备金时考虑诸多因素。在授权范围内协商并解决理赔。指导低级别理赔专员。协调特殊项目并为他人提供指导。候选人必须有加州经验。
ESSENTIAL DUTIES AND RESPONSIBILITIES 包括以下内容。其他职责可能被指派。
- 核实雇主和受伤员工的工伤保险覆盖情况。
- 通过彻底调查理赔案件，确定工伤保险下的可赔付性。
- 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。
- 根据理赔档案的特性，在授权范围内根据预期财务风险及时建立适当的准备金。
- 记录具有代位追偿可能的理赔细节，包括潜在追偿金额。
- 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。根据治疗方案和显示治疗与伤害之间关系的医疗支持，批准付款。
- 在理赔解决后结案，以满足内部绩效标准，同时遵守州立法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，以使案件最终结案。
- 与经理密切合作处理复杂案件或超出和解/准备金授权范围的案件。
- 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。
- 跟踪工伤保险法规、判例法以及康复工作的变化和进展，以便准确解释和应用相关法律。
- 指导团队成员。
- 对理赔文件进行审计。
- 作为团队领导的后备人员。
- 协调特殊项目。
EDUCATION AND EXPERIENCE
- 可考虑教育和经验的相关组合代替学位。
- 本科学历相关专业
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SUMMARY
This is the advanced level of the claim handler career path. Investigates claims and exercises significant discretion in the determination of compensability of claims. May handle large, more complex customers requiring high touch, labor intensive claim service. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority. Mentors lower-level claim handlers. Coordinates special projects and provides guidance to others. Candidate must have California experience.
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.
- Mentors team members.
- Conducts audits of claim files.
- Acts as a backup for team leader.
- Coordinates special projects.
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.
- Five (5) 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 complex workers’ compensation claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred.
- OR
- Two (2) years of AF Group Claims Representative II experience that includes discretion in determining compensability of complex claims and/or handling complex, high touch or labor-intensive customers.
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 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.
- Ability to train and mentor others.
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 $64,900 and $108,7000.
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.
#AFG
Originally posted on Himalayas