Senior Claims Representative

This is a fully remote position, open to applicants in Illinois, +5 more states.

📋 Description

• Manage intricate workers’ compensation claims with substantial financial implications, legal complexities, and prolonged life cycles.

• Execute thorough investigations regarding coverage, compensability, fraud, and loss prevention.

• Supervise medical case management for severe injuries and long-term care requirements.

• Evaluate and authorize substantial or complicated medical bills, negotiating adjustments to manage expenses.

• Collaborate with policyholders, legal advisors, and vocational consultants to formulate return-to-work strategies.

• Ensure precise benefit calculations for high-exposure claims.

• Perform subrogation analysis and engage in negotiations with third-party insurers or attorneys to maximize recovery.

• Work in partnership with legal teams on complex settlements and litigation matters.

• Manage Medicare compliance initiatives, including Medicare Set-Asides and engagement with CMS.

• Recognize structured-settlement opportunities and spearhead negotiations.

• Generate strategic reports on high-profile claims and prepare documentation for Corporate Plan of Action meetings.

• Facilitate cross-departmental improvements in claims handling and risk management.

• Address escalated customer service concerns and support high-value accounts.

• Engage in workflow enhancement initiatives and committee participation.

• Mentor and guide junior and intermediate adjusters.

• Review escalated claims and provide constructive feedback.

• Contribute to workforce development and succession planning.

⛳️ Requirements

• 7–10 years of experience in claims handling, particularly with high exposure to Workers’ Compensation.

• Bachelor’s degree in business or a related field is preferred, or equivalent industry experience.

• Associate in Claims (AIC), AIM, or CPCU designation is preferred, or the ability to obtain one.

• Texas All-Lines license is preferred.

• A valid driver’s license is required.

• Capability to manage highly complex, high-exposure workers’ compensation claims.

• Proficiency in conducting advanced investigations regarding coverage, compensability, fraud, subrogation, and loss prevention.

• Familiarity with nuanced statutory interpretations and regulatory compliance.

• Experience in supervising medical case management for severe injuries and long-term care needs.

• Background in reviewing and authorizing substantial or intricate medical bills and negotiating adjustments.

• Experience in developing return-to-work strategies and calculating benefits while addressing tax and compliance risks.

• Skilled in negotiating complex settlements, managing litigation processes, Medicare Set-Asides, and CMS engagement.

• Ability to produce strategic claims reports and maintain data integrity within systems.

• Competence in mentoring and coaching junior and intermediate adjusters.

🏝️ Benefits

• Medical, dental, and vision health plans, including fertility benefits, fully covered preventive care, and adult orthodontia.

• Employer-funded life insurance equivalent to 3x base salary.

• Employer-covered AD&D insurance.

• Employer-provided short- and long-term disability insurance.

• Employer-sponsored wellness and recognition incentives for employees and their spouses.

• Flexible Spending Accounts and dependent care options available.

• Health Savings Account with a generous employer contribution.

• Generous paid time off policies.

• 11 holidays and 4 early release days.

• 16 hours of volunteer time off.

• 20 days of paid parental leave.

• Leave for marriage, bereavement, and jury duty.

• Employee Assistance Programs available.

• 401(k) retirement plan with employer matching and profit sharing.

• Adoption assistance offered.

• Tuition assistance provided.