Senior Claims Representative

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

📋 Description

• Oversee intricate claims that involve substantial financial risk, legal complexities, and lengthy durations.

• Perform in-depth investigations regarding coverage and compensability, including detailed interpretations of statutory regulations.

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

• Evaluate and approve significant or complicated medical invoices, negotiating modifications to manage expenses.

• Create thorough Return-to-Work strategies in partnership with policyholders, legal advisors, and vocational specialists.

• Ensure accuracy in benefit calculations for high-risk claims, addressing potential tax and compliance challenges.

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

• Spearhead investigations into intricate fraud cases and work closely with the Special Investigations Unit.

• Conduct analysis on subrogation and negotiate with third-party insurers or legal representatives for optimal recovery.

• Collaborate with legal teams to negotiate complicated settlements and oversee litigation processes.

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

• Identify avenues for structured settlements and lead negotiation efforts.

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

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

• Direct cross-departmental initiatives to enhance claims processing and risk management.

• Address escalated customer service challenges and assist high-value accounts.

• Engage in initiatives and committees aimed at workflow improvements.

• Mentor and guide junior and intermediate adjusters.

• Review escalated claims and provide constructive feedback.

• Contribute to workforce development and succession planning.

⛳️ Requirements

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

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

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

• Texas All-Lines license is preferred.

• A valid driver’s license is a requirement.

🏝️ Benefits

• Health Plans: Medical, Dental, and Vision

• Employer-Paid Life and Disability Benefits: Life Insurance (3x base salary), AD&D, Short and Long-term Disability.

• Wellness and Recognition Program: Employer-paid incentives for employees and their spouses.

• Flexible Spending Account and Dependent Care options

• Health Savings Account: Generous employer contributions.

• Time Away from Work: Generous PTO, 11 Holidays + 4 Early Releases, 16 Hours Volunteer Time Off, 20 Days Paid Parental Leave, Marriage, Bereavement, and Jury Duty leave.

• Employee Assistance Programs

• 401k Retirement Plan: Employer match and profit sharing.

• Adoption Assistance and Tuition Assistance