Sr Claim Representative - Workers Compensation - Walnut Creek, CA

Sr Claim Representative - Workers Compensation - Walnut Creek, CA

Under general supervision, manage Workers' Compensation claims with lost time to conclusion and negotiate settlements where appropriate to resolve claims. Coordinate medical and indemnity position of the claim with a Medical Case Manager. Independently handles assigned claims of low to moderate complexity where Wage loss and the expectation is a return to work to modified or full duty or obtain MMI with no RTW. There are no litigated issues or minor to moderate litigated issues. The claim may involve minor sprains / minor to moderate surgery. The Injured worker is working modified duty and receiving ongoing medical treatment. The injured worker has returned to work, reached Maximum Medical Improvement (MMI) and is receiving PPD benefits. File will close as soon as the PPD is paid out. Independently handles all assigned claims up to and including most complex where Injured worker (IW) remains out of work and unlikely to return to position. Employer is unable to accommodate the restrictions. The claim involves moderate to complex litigation issues IW has returned to work, reached Maximum Medical Improvement (MMI), and has PPD. File litigated to dispute the permanency rating and / or causality. IW has been released to work with permanent restrictions and job is no longer available. IW is receiving Vocational Rehabilitation. Claims that have been reopened for additional medical treatment on more complex files. Injuries may involve one or multiple back, shoulder or knee surgeries, knee replacements, claims involving moderate to complex offsets, permanent restrictions and / or fatalities. Claims on which a settlement should be considered.

Conduct investigations, including, but not limited to assessing policy coverage, contacting insureds, injured workers, medical providers, and other parties in a timely manner to determine compensability. Establish and update reserves to reflect claim exposure and document rationale. Identify and set actuarial reserves. Apply knowledge to determine causal relatedness of medical conditions. Manage files with an emphasis on file quality (including timely contact and proper documentation and proactive resolution of outstanding issues). Achieve a positive end result by returning injured party to work and coordinating the appropriate medical treatment in collaboration with internal nurse resources where appropriate. Develop strategies to manage losses involving issues of statutory benefit entitlement, medical diagnoses, Medicare Set Aside to achieve resolution through the best possible outcome. Work in collaboration with specialty resources (i.e. medical and legal) to proactively pursue claim resolution opportunities, (i.e. return to work, structured settlement, and discontinuation of benefits through litigation). Develop strategies to manage losses involving issues of statutory benefit entitlement, medical diagnoses, Medicare Set Aside to achieve resolution through the best possible outcome Collaborate with our internal nurse resources (Medical Case Manager) in order to integrate the delivery of medical services into the overall claim strategy. Prepare necessary letters and state filings within statutory limits. Pursue all offset opportunities, including apportionment, contribution and subrogation. Evaluate claims for potential fraud. Proactively manage inventory with documented plans of action to ensure timely and appropriate file closing or reassignment. Proactively manage moderate to complex litigation to drive files to an optimal outcome, including resolution of benefits. Understand and apply Medicare Set Asides and allocations. Negotiate settlement of claims within designated authority. May use structured settlement / annuity as appropriate for the jurisdiction. Apply deep technical expertise to assist in the resolution of highly complex claims. Mentor other Claim Professionals Participate in Telephonic and / or onsite File Reviews. Respond to inquiries verbal and written. Keep injured worker apprised of claim status Act as technical resource to others. Participate in Telephonic and / or onsite File Reviews. Respond to inquiries verbal and written. Keep injured worker apprised of claim status. Act as technical resource to others. Engage specialty resources as needed. Performs other assigned duties which may include : Applies deep technical / subject matter expertise to assist in the resolution of complex claims. Acts as an independent mentor to other Claim Professionals.

In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated. Maintain Continuing Education requirements as required. Perform other duties as assigned.

What Will Our Ideal Candidate Have? Education / Course of Study : Work Experience : Analytical Thinking : Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause / effect relationships; and explores alternative solutions that support sound decision-making. Communication : Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Ability to effectively present file resolution to internal and / or external stakeholders. Negotiation : Advanced evaluation, negotiation and case resolution skills. Ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise. General Insurance Contract Knowledge : Interprets policies and contracts, applies loss facts to policy conditions, and determines whether or not a loss comes within the scope of the insurance contract. Principles of Investigation : Intermediate investigative skills including the ability to take statements. Follows a logical sequence of inquiry with a goal of arriving at an accurate reconstruction of events related to the loss. Value Determination : Advanced ability to determine liability and assigns a dollar value based on damages claimed and estimates, sets and readjusts reserves. Settlement Techniques : Advanced ability to assess how a claim will be settled, when and when not to make an offer, and what should be included in the settlement offer package. Legal Knowledge : Thorough knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry. Medical knowledge : Intermediate knowledge of the nature and extent of injuries, periods of disability, and treatment needed. WC Technical : Advanced ability to demonstrate understanding of WC Products and ability to apply available resources and technology to resolve claims. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state. Advanced knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry. Customer Service : Advanced ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes Teamwork : Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result Planning & Organizing : Advanced ability to establish a plan / course of action and contingencies for self or others to meet current or future goals What is a Must Have? High school diploma or equivalent required Minimum of 2 years Workers Compensation claim handling experience