Workers Compensation Claims Representative II
Society Insurance - Fond du Lac, WI

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Primary Purpose
With minimal manager assistance, resolves moderate-to-severe Workers’ Compensation claims by investigating, evaluating, documenting and negotiating settlements within established standards.

Essential Functions and Responsibilities
(Other duties may be assigned)
  • Investigates moderate-to-severe workers’ compensation claims, by conducting recorded telephone statements of injured workers, insureds and witnesses and documenting claim files with results.
  • Determines the insurance carrier’s liability by reviewing the facts of the claims, setting claim reserves, calculating and paying the appropriate benefits.
  • Determines the desirability of obtaining records review and independent medical examinations (IME) by reviewing the facts of the claim and posing questions to independent medical personnel and taking the appropriate action with the results.
  • Resolves disputed claims independently or with attorney assistance by analyzing state statutes, evaluating evidence and developing a claim resolution strategy.
  • Promotes early return to work by communicating and coordinating between involved parties.
  • Acts as main contact for large/dedicated insureds by scheduling meetings to review claims, discussing opportunities for better claim resolution, and providing information regarding new cost containment programs.
  • Pursues subrogation recoveries from potentially responsible third parties with minimal manager guidance by reviewing the claim facts and determining liability.
  • Communicates decisions on claims by responding to communications from: managers, injured workers, injured worker’s counsel, insureds, agents, health care providers, state administrators and others.
  • Determines the need for medical and vocational management by reviewing the severity of the claim, assigning vendors and directing their activities with minimal manager guidance.
  • Ensures accurate file documentation by complying with company procedures and state requirements.
  • Keeps current with claims through follow-up discussions with injured workers and insureds; makes recommendations to manager regarding reserve changes and future handling of files based on claim facts.

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, skills, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Bachelor’s degree in business or related field and 3+ years of workers’ compensation adjusting experience.

5+ years of workers’ compensation adjusting experience involving the exercise of discretionary decision-making and increasing levels of claim severity as determined by Society Insurance.
  • Valid driver’s license and a satisfactory driving record as determined by Society Insurance.
  • Bachelor’s degree with 3+ years of workers’ compensation claims handling experience.
  • Proficient investigative skills, demonstrated through experience.
  • Continued education in and/or experience with medical terminology and workers’ compensation laws and procedures.
  • Completed 2 components of the AIC designation or equivalent.
  • Demonstrated knowledge of insurance policies and coverage, claim payment procedures, insurance regulations, and understanding of medical and legal terminology.
  • Demonstrated knowledge of general office equipment (computer, telephone, calculator/adding machine, fax machine, headsets and copy machines).

Society Insurance - 16 months ago - save job - copy to clipboard
About this company
Company Overview: Society Insurance is a mid-sized, commercial lines insurance company located in Fond du Lac, Wisconsin. We are...