Workers Compensation - Sr. Claims Rep

To provide prompt, cost effective and efficient examination, investigation and settlement or

denial of insurance claims up to the highest and most severe exposure with minimal

supervision, by exercising independent decision making skills and judgment.

1.      Adjust a caseload of assigned files in accordance with Meadowbrook Insurance Group’s policies and procedures.

2.      Maintain an active diary on 100% of caseload files, with a current plan of action.

3.      Adhere to assigned authority limits for reserving and payments (including settlements).

4.      Exercise independent decision-making skills with minimal to moderate supervision and direction on claims assigned, using knowledge of local codes, laws, standards and case-law.

5.      Verify coverage, investigate the loss by gathering all pertinent information, evaluate the claim, set reserves, negotiate settlements or deny payments where no overage, liability or compensability exists.

6.      Record statements, obtain documentation such as police reports, medical reports, appraisals, estimates, photographs, etc. to process claims in accordance with Company standards.

7.      Evaluate loss, assess reserve and settlements value where applicable and settle cases with claimants, insureds and attorneys autonomously. 

8.      Decide on denial of coverage, liability or compensability.

9.      Assure all litigation cases are handled effectively and cost efficiently until legal settlement has been reached or judgment has been awarded, including decisions to award appeals, as assigned by Branch Management. 

10.  Identify and thoroughly investigate all possible recovery and subrogation opportunities revealed in the claims handled. 

11.  File all state and/or federal forms, filings and reports in accordance with the statutory Guidelines.

12.  Process all medical bill and indemnity payments in accordance with statutory and/or office policy timeframes.  Process medical bills through applicable cost-containment procedures on a timely basis, as set by office guidelines or statutory allowances (Workers Compensation Representatives only).

13.  Work closely with the Loss Control department to return claimants to work and will notify Loss Control immediately if a policyholder is uncooperative in return-to-work efforts (Workers Compensation Representatives only).

14.  Return all telephone calls within one (1) business day, when possible.  All messages from customers and agents are to be returned by the end of the same business day in which the call was received.  Reports all service complaints to Claims Supervisor or Claims Manager immediately upon receipt.

15.  Maintain personal compliance with all continuing education requirements as mandated by statute or by office policy.

16.  Manually or electronically document files in a timely fashion with all appropriate information, in a legally accepted, factual manner.

17.  Scope losses and write estimates up to $100,000 or greater. (Property Representatives only).

18.  Write pro-forma balance sheets and income statements on Business interruption losses (Property/Casualty).

19.  Understand coverage issues with good knowledge of exclusions, endorsements on standard ISO forms.

20.  Conduct preliminary investigations, including fire scenes, accident scenes, and/or burglary losses.

21.  Negotiate settlement based upon scope, estimate, coverage interpretations, accident scene investigation and income statements developed.

22.  Provide training to other Claims personnel when required by Claim Management. 

23.  Recognize settlement or exposure value and be able to use tools to assist in settling cases, such as structured settlements, arbitration, mediation, etc.

24.  Must adhere to the company code of ethics.

25.  Professional and timely communication with all internal and external vendors.

26.  Performs related duties as assigned.

1.      Five (5) or more years adjusting experience is required.

2.      College degree or equivalent experience.

3.      Current and valid State adjusting license when and where applicable.

4.      Ability to prioritize daily workflow of a moderate technical complexity.

5.      Excellent written and oral communication skills.

6.      Detail orientated, with excellent organizational and planning skills.

7.      Ability to work independently and with initiative is essential.

8.      Experience negotiating settlements both telephonically and in person with attorneys, mediators, judges or other carrier personnel.

9.      Thorough knowledge of claim procedures, policies, terminology, etc.

10.  Thorough understanding of the Workers Compensation Act(s), coverage under Sections A and B of the policy and Insurance Department regulations (Workers Compensation Representatives only).

11.  Thorough knowledge of differences in techniques, medical care available and vocational possibilities within geographic areas of the state(s) (Workers Compensation Representatives only).

12.  Working knowledge of civil procedure, petitions, complaints, Department of Insurance operations audits.

13.  Demonstrate strong problem-solving and analytical ability.

14.  Must have successfully completed one or more of the educational programs through the Insurance Institute of America or the Professional Insurance Agents, such as, Chartered Property Casualty Underwriter (CPCU), Program in General Insurance, Associate in Claims (AIC), etc.

15.  Spanish bilingual desirable or other languages.

16.  Possess a valid driver’s license.

17.  Ability to travel as necessary.

18.  Handle files in good faith as defined by statute, case-law and Corporate standards.

19.  Computer proficient with Microsoft Office programs.