Senior Claims Representative

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

📋 Description

• Manage intricate claims that involve substantial financial risk, legal complexities, and prolonged timelines.

• Conduct thorough investigations into coverage and compensability, including detailed statutory interpretations.

• Supervise medical case management for severe injuries and ongoing care requirements.

• Evaluate and authorize substantial or complicated medical expenses and negotiate adjustments to manage costs effectively.

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

• Ensure accuracy in benefit calculations for high-exposure claims, addressing tax implications and compliance risks.

• Strategically implement investigative activities that align with the overall claims strategy.

• Lead intricate fraud investigations and work in conjunction with the Special Investigations Unit.

• Perform subrogation analyses and negotiate with third-party insurers or attorneys to maximize recoveries.

• Negotiate complex settlements and oversee litigation processes alongside legal teams.

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

• Identify prospects for structured settlements and take charge of negotiations.

• Generate strategic reports on high-profile claims to inform management decisions.

• Maintain data integrity within systems and prepare claims for Corporate Plan of Action meetings.

• Lead interdepartmental efforts to enhance claims management and risk mitigation.

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

• Engage in initiatives and committees focused on workflow enhancements.

• Mentor and guide junior and intermediate adjusters.

• Review escalated claims and offer constructive feedback.

• Contribute to workforce development and succession planning.

⛳️ Requirements

• A bachelor’s degree in business or a related field is preferred, or equivalent relevant experience.

• 7 to 10 years of experience in claims handling, particularly with a strong focus on Workers’ Compensation.

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

• A Texas All-Lines license is preferred.

• A valid driver’s license is required.

🏝️ Benefits

• Medical, dental, and vision health plans.

• Fertility benefits.

• Fully covered preventative care.

• Adult orthodontia.

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

• Employer-paid AD&D.

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

• Wellness and recognition program with employer-funded incentives for employees and their spouses.

• Flexible Spending Account and dependent care options.

• Health Savings Account with generous employer contributions.

• Generous paid time off (PTO).

• 11 holidays plus 4 early releases.

• 16 hours of volunteer time off.

• 20 days of paid parental leave.

• Leave for marriage, bereavement, and jury duty.

• Employee Assistance Programs.

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

• Adoption assistance.

• Tuition assistance.