Claims Representative

Overview

Investigates, evaluates, and handles assigned claims through final disposition in accordance with company procedures. Investigates coverage and compensability issues. Handles lost time claims to include medical case management, litigation management, return to work, and settlement when necessary. Uses technology and systems to manage claims, to include document management, utilization review, and pharmacy management. Develops skillset to proactively manage caseload, to include time management, decision making skills, and having difficult conversations.

Major Areas of Accountability

• Investigates assigned claims following sound claim handling techniques in accordance with company claim philosophy and quality assurance standards. 
• Responsible for investigating and determining coverage, compensability, and subrogation potential on every claim, including second injury fund and longshore 8(f) special fund. 
• Determines proper jurisdiction and classifies each claim under state, federal, or maritime class codes.
• Establishes and adjusts reserves or provides reserve recommendations to establish the value of the claim consistent with corporate policies and within assigned authority levels.
• Evaluates and negotiates settlements of claims within assigned authority level.
• Manages all litigation issues arising under assigned claims, to include coverage, compensability, medical causation, return to work issues, and any other issues under the law. 
• Responsible for medical case management, utilization review, return to work, pharmacy management, and settlement/mitigation when necessary.
• Continuously communicates with injured workers, policyholders, agents, medical providers, plaintiff attorneys, and defense attorneys.
• Maintains a heightened focus on learning applicable laws, regulations, and medical guidelines. 
• Documents claim files with necessary information to confirm all claim issues.  Provides appropriate level of service to agents and policyholders.
• Complies with all customer service standards.  Responds promptly to resolve complaints or claim problems. Manages personal claim caseload effectively and in accordance with productivity and claim cost objectives.
• Takes initiative and manages personal claim caseload in accordance with processes and procedures with a focus on individual, team, and departmental goals.
• Performs other job duties as needed by the department.

Personality/Working Style

• Strong character
  • Alignment with company values, mission, and vision
  • Trustworthy and honest
  • Decisive
  • Curious and persistent
  • Commitment to accountability
• Passion for innovation
  • Willingness to learn
  • Adaptive to changing (tolerance for ambiguity)
  • Desire to collaborate to achieve corporate goals
• Strong communicator
  • Effective communication skills
  • Empathetic listener and open-minded
  • Focus on customer service and stakeholder experience
  • Effectively handle difficult conversations
  • Effective use of persuasion
• Skills required
  • Computer literate
  • Math
  • Judgement
  • Problem solving

Education and Experience

• Education Required:
  • Bachelor’s degree and a minimum of two (2) years handling claims  
  • In lieu of a bachelor’s degree, a candidate with a high school diploma/GED with four (4) years handling claims may be considered
  • A high school diploma/GED, CPCU designation and two (2) years of claims handling experience may also be considered in lieu of a college degree.
• Internal candidates may be considered based on demonstrated performance, including consistent achievement or exceedance of established goals, strong time‑management and decision‑making capabilities, and effective handling of lost time claims.
• Active Louisiana Workers' Compensation Adjuster License required prior to start or obtained within seven (7) business days after start date. Employee is required to maintain their continuing education units and up-to-date adjuster license.