Primary Job Duties & Responsibilities
Completes required training program which includes the overall instruction, exposure, and preparation for employees to progress to the next level position. It is a mix of online, virtual, classroom, and on-the-job training.
The training may require travel. The on the job training includes practice and execution and coaching on the following core assignments: Conduct investigations, including, but not limited to assessing policy coverage, investigation of non-questionable/questionable claims, contacting insureds, injured workers, medical providers, and other parties in a timely manner to determine compensability.
Proactively manage inventory with documented plans of action and emphasis on file quality and data integrity to ensure timely and appropriate resolution or reassignment. 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. Manage, resolve or reassign those claims where pre-injury return to work is unlikely.
Establish and update reserves to reflect claim exposure and document rationale. Identify exposures and establish appropriate reserves. Apply knowledge to determine causal relatedness of medical conditions.
Collaborate with internal nurse resources (Medical Case Manager) in order to integrate the delivery of medical services into the overall claim strategy. Complete required letters and state forms and any other required documents as required. Prepare necessary letters and state filings within statutory limits.
Determine and actively develop ongoing strategic plans for resolution as required. 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.
Pursue all offset opportunities, including apportionment, contribution and subrogation. Evaluate claims for potential fraud. Effectively manage 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. Evaluate and document a detailed settlement analysis, value and range.
Refer claims beyond authority as appropriate based on exposure and established guidelines. May use structured settlement/annuity as appropriate for the jurisdiction. Participate in Telephonic and/or onsite File Reviews.
Respond to inquiries - verbal and written. Keeping injured worker apprised of claim status. Communicate and complete denials on medical and indemnity issues.
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. In order to progress to Claim Representative, a Trainee must demonstrate proficiency in the skills outlined above.
Proficiency will be verified by appropriate management, according to established standards. Perform other duties as assigned.
Job Specific & Technical Skills & Competencies
Demonstrated ownership attitude and customer centric response to all assigned tasks
Basic Verbal and written communication skills
Intermediate Attention to detail ensuring accuracy
Basic Ability to work in a high volume, fast paced environment managing multiple priorities
Basic Analytical Thinking
Basic Judgment/ Decision Making
This is an entry level position that requires satisfactory completion of required training to advance to a Workers' Compensation claim professional position. This position is intended to develop skills for investigating, evaluating, negotiating and resolving claims on losses of lesser value and complexity. Provides quality claim handling throughout the claim life cycle (customer contacts, coverage, investigation, evaluation, reserving, negotiation and resolution) including maintaining full compliance with internal and external quality standards and state specific regulations. As part of the hiring process, this position requires the completion of an online pre-employment assessment. Further information regarding the assessment including an accommodation process, if needed, will be provided at such time as your candidacy is deemed appropriate for further consideration. This job does not manage others This job works under Close Supervision: Work is reviewed at several steps along the way. (Generally pertains to trainee positions.)
Education, Work Experience & Knowledge
Bachelor's Degree preferred or a minimum of 2 years of work OR customer service related experience preferred.
Operates standard office equipment
Frequently Sitting (can stand at will)
Occasionally Use of Keyboards, Sporadic 10-Key
High School Diploma or GED and one year of customer service experience OR Bachelor's Degree required.
The Travelers Companies