Senior Claims Representative

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

📋 Description

• Supervise intricate claims that involve substantial financial implications, legal complexities, and prolonged life cycles.

• Perform in-depth investigations regarding coverage and compensability, which includes statutory interpretations.

• Manage medical case oversight for severe injuries and lifelong care requirements.

• Evaluate and authorize sizable or complicated medical bills, negotiating adjustments to manage costs effectively.

• Create return-to-work strategies in collaboration with policyholders, legal advisors, and vocational consultants.

• Ensure precise benefit calculations while addressing tax and compliance-related risks.

• Implement investigative initiatives with strategic intent.

• Direct intricate fraud investigations alongside the Special Investigations Unit.

• Conduct subrogation analyses and negotiate with third-party insurers or attorneys to maximize recovery.

• Collaborate with legal teams on complex settlement agreements and litigation processes.

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

• Identify opportunities for structured settlements and spearhead negotiations.

• Generate strategic reports on high-profile claims to assist management decision-making.

• Maintain the integrity of system data and prepare claims for Corporate Plan of Action meetings.

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

• Resolve escalated customer service concerns while supporting high-value accounts.

• Engage in workflow enhancement initiatives and committees.

• Mentor and guide junior and intermediate adjusters.

• Review escalated claims and deliver actionable feedback.

• Contribute to workforce development and succession planning.

⛳️ Requirements

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

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

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

• Texas All-Lines license is preferred.

• A valid driver’s license is required.

• Ensure adherence to regulatory standards.

• Experience managing highly complex, high-exposure workers’ compensation claims.

• Advanced skills in coverage and compensability investigations.

• Medical case management expertise for catastrophic injuries and long-term care needs.

• Proficient in complex medical bill review and negotiations.

• Ability to develop return-to-work strategies.

• Familiarity with benefit calculations for high-exposure claims, addressing tax and compliance risks.

• Experience in conducting complex fraud investigations.

• Knowledge of subrogation analysis and negotiation techniques.

• Expertise in complex settlement negotiations and litigation management.

• Familiarity with Medicare compliance, Medicare Set-Asides, and CMS engagement.

• Strategic reporting on claims and maintaining data integrity within claims systems.

• Experience in mentoring and coaching adjusters.

🏝️ Benefits

• Medical, dental, and vision health plans.

• Fertility benefits.

• Fully covered preventative care.

• Adult orthodontics.

• Employer-paid life insurance (3x base salary).

• Employer-paid AD&D insurance.

• Employer-paid short- and long-term disability.

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

• Flexible Spending Account.

• Dependent Care options.

• Health Savings Account with a generous employer contribution.

• Generous paid time off (PTO).

• 11 holidays and 4 early release days.

• 16 hours of volunteer time off.

• 20 days of paid parental leave.

• Marriage leave.

• Bereavement leave.

• Jury duty leave.

• Employee Assistance Programs.

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

• Adoption assistance.

• Tuition assistance.