Work Comp Claims Rep I

Santa Ana, CA - USA

Monthly Salary: Not Disclosed

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

AMERIND is a federally chartered tribally owned corporation formed under Section 17 of the Indian Reorganization Act (25 U.S.C. 5124) by its Members the governmental units of federally recognized Tribal Nations that administer federally funded housing programs for American Indian and Alaska Native families. AMERIND has the operating authority to work with Tribal Governments Enterprises and Citizens for Property and Liability Workers Compensation Homeowners and Renters Employee Benefits coverage Fleet Auto coverage and Critical Infrastructure development.

Position Characteristics and Competencies

Strong problem-solving and analytical thinking
Strong verbal and written communication skills
Interest in discovering and developing new ideas
Strong customer service skills both verbally and in writing
Agile and adaptable in decision making
Transparent and interactive in projects and reporting
Trustworthy as a company rep; forthcoming communicative and people-oriented

Job Summary

Incumbent handles Tribal Workers Compensation claims. Responsible for all technical aspects of claim management for assigned files including compliance with the AMERIND Risk Benefit Endorsement Tribal Ordinances (when applicable) and all established performance guidelines. Caseload will consist of medical-only claims and less complicated lost time claims. Should also have familiarity with general claims handling software. This individual demonstrates positive and professional relationships with Members Brokers and clients.

This job description does not represent an inclusive list of all duties encompassed in this position.

Job Responsibilities

Interacts with customers and associates over the telephone in person and in written correspondence to establish and improve communication and service capabilities.
Properly investigates and handles workers compensation files including medical-only claims and less complicated loss time claims within predetermined claim-handling guidelines.
Takes initial calls and provides instructions on claim filing requirements.
Initiates return-to-work discussions with the employer and effects return-to-work for the injured worker on lost time claims.
Interviews claimants specialists witnesses physicians or other professionals as necessary.
Determines compensability and total value of claim; negotiates settlements and makes recommendations regarding litigation.
Establishes timely and appropriate case reserves.
Investigates and manage subrogation and negotiate settlements.
Interacts and consults with attorneys and other providers regarding claims to control costs and assist in making decisions and actions.
Negotiates directly with the claimants as necessary.
Prepares and presents arguments to the Hearing Examiner on claims going through the Dispute Resolution process.
Uses automated diary system to issue indemnity benefits and provide claim management.
Accurately calculates and pays wage loss and other benefits on lost time claims.
Reviews and follows up on claims as needed and closes files as appropriate.
Documents all action plans and evaluations for claim resolution.
Maintains organized electronic files.
Addresses customer complaints and inquiries in an exemplary and professional manner.
Achieves specific performance outcomes related to quality and quantity of work as established by management.
Provides cost containment for individual claims and overall claim costs for the account to achieve account profitability.
Conducts in-person claim reviews when scheduled or requested.
Performs the duties noted in the position descriptions in accordance with AMERIND Risk WC Claim Handling Guidelines.
Performs a variety of assignments that may be confidential in nature; enters data drafts edits revises and print letters tables reports and other materials as necessary.
Maintains confidentiality of all information.
Participates in cross-functional team process improvement projects.
Performs other duties as assigned.

Supervision of Others

N/A

Minimum Qualifications

High School Diploma or GED required.
Associate degree in insurance Economics Business Administration or related field is preferred.
Basic insurance knowledge required.
Designations and certificates from accredited insurance institutions are preferred.
Minimum of three years of workers compensation claims handling experience required.
Minimum of three years experience using carrier risk information system software required.
Must possess a valid drivers license.
Must be able to successfully pass a background investigation. No felony theft or fraud convictions.

Additional Eligibility Requirements

New employees must complete the Associate in Insurance (AINS) designation within six months from the end of the 90-day evaluation period to be eligible for advancement and incentive compensation.
For continued employment employees must complete an elective course and six hours of professional development within 12 months after the end of the 90-day evaluation period.

Knowledge/Skills/Abilities

Demonstrates working knowledge of workers compensation administration rules/laws and/or Tribal Work Comp experience preferred.
Familiarity with technology infrastructure and user of technology tools.
Knowledge of medical and insurance terminology and of claims processing practices.
Ability to communicate effectively in the English language both verbally and in writing.
Ability to analyze situations and adopt appropriate courses of action.
Ability to work effectively under stressful conditions.
Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds employees and officials.
Ability to develop and interpret policies procedures and regulations.
Ability to maintain an accurate and organized filing system of complex insurance records and reports.
Ability to handle multiple tasks and meet deadlines.
Ability to exercise independent judgment.
Ability to train and present information to others.
Ability to speak and present in claim reviews.
Ability to follow oral and written instruction.
Ability to collect and analyze data and prepare and present accurate reports and recommendations.
Ability to act with integrity and maintain confidentiality.
Skill in performing statistical and mathematical computations.
Skill in preparing presenting reviewing and analyzing insurance claims forms and reports.
Skill in providing excellent customer service.
Skill in operating business computers and office machines including in a Windows environment specifically Word Excel Access and presentation software (such as PowerPoint).
Database management skills.
Excellent telephone communication skills.

Working Conditions & Physical Demands

Typical business office setting with moderate noise level.
Non-office environment may be encountered for offsite presentations and support of company activities.
Must be able to sit for work at a computer and phone for more than 6 hours per day.
Must be able to speak clearly.
Must be able to use hands for dexterity of motion.
Frequently required to stand walk and reach with hands and arms.
Must have ability to occasionally lift 20 lbs.
Must be willing to travel as necessary which may require overnight stays.

Physical Exam

Required to successfully pass an annual physical exam to certify that the incumbent is capable of performing the physical demands of the job as described above.

Hiring of AMERIND employees is subject to Section 7(b) of the Indian Self-Determination Act (25 U.S.C. 5307(b)) which requires that to the greatest extent feasible preference and opportunities for training and employment shall be given to Native Americans and Alaska Natives.

Position Characteristics and Competencies

Strong problem-solving and analytical thinking
Strong verbal and written communication skills
Interest in discovering and developing new ideas
Strong customer service skills both verbally and in writing
Agile and adaptable in decision making
Transparent and interactive in projects and reporting
Trustworthy as a company rep; forthcoming communicative and people-oriented

Job Summary

This job description does not represent an inclusive list of all duties encompassed in this position.

Job Responsibilities

Interacts with customers and associates over the telephone in person and in written correspondence to establish and improve communication and service capabilities.
Properly investigates and handles workers compensation files including medical-only claims and less complicated loss time claims within predetermined claim-handling guidelines.
Takes initial calls and provides instructions on claim filing requirements.
Initiates return-to-work discussions with the employer and effects return-to-work for the injured worker on lost time claims.
Interviews claimants specialists witnesses physicians or other professionals as necessary.
Determines compensability and total value of claim; negotiates settlements and makes recommendations regarding litigation.
Establishes timely and appropriate case reserves.
Investigates and manage subrogation and negotiate settlements.
Interacts and consults with attorneys and other providers regarding claims to control costs and assist in making decisions and actions.
Negotiates directly with the claimants as necessary.
Prepares and presents arguments to the Hearing Examiner on claims going through the Dispute Resolution process.
Uses automated diary system to issue indemnity benefits and provide claim management.
Accurately calculates and pays wage loss and other benefits on lost time claims.
Reviews and follows up on claims as needed and closes files as appropriate.
Documents all action plans and evaluations for claim resolution.
Maintains organized electronic files.
Addresses customer complaints and inquiries in an exemplary and professional manner.
Achieves specific performance outcomes related to quality and quantity of work as established by management.
Provides cost containment for individual claims and overall claim costs for the account to achieve account profitability.
Conducts in-person claim reviews when scheduled or requested.
Performs the duties noted in the position descriptions in accordance with AMERIND Risk WC Claim Handling Guidelines.
Performs a variety of assignments that may be confidential in nature; enters data drafts edits revises and print letters tables reports and other materials as necessary.
Maintains confidentiality of all information.
Participates in cross-functional team process improvement projects.
Performs other duties as assigned.

Supervision of Others

N/A

Minimum Qualifications

High School Diploma or GED required.
Associate degree in insurance Economics Business Administration or related field is preferred.
Basic insurance knowledge required.
Designations and certificates from accredited insurance institutions are preferred.
Minimum of three years of workers compensation claims handling experience required.
Minimum of three years experience using carrier risk information system software required.
Must possess a valid drivers license.
Must be able to successfully pass a background investigation. No felony theft or fraud convictions.

Additional Eligibility Requirements

New employees must complete the Associate in Insurance (AINS) designation within six months from the end of the 90-day evaluation period to be eligible for advancement and incentive compensation.
For continued employment employees must complete an elective course and six hours of professional development within 12 months after the end of the 90-day evaluation period.

Knowledge/Skills/Abilities

Demonstrates working knowledge of workers compensation administration rules/laws and/or Tribal Work Comp experience preferred.
Familiarity with technology infrastructure and user of technology tools.
Knowledge of medical and insurance terminology and of claims processing practices.
Ability to communicate effectively in the English language both verbally and in writing.
Ability to analyze situations and adopt appropriate courses of action.
Ability to work effectively under stressful conditions.
Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds employees and officials.
Ability to develop and interpret policies procedures and regulations.
Ability to maintain an accurate and organized filing system of complex insurance records and reports.
Ability to handle multiple tasks and meet deadlines.
Ability to exercise independent judgment.
Ability to train and present information to others.
Ability to speak and present in claim reviews.
Ability to follow oral and written instruction.
Ability to collect and analyze data and prepare and present accurate reports and recommendations.
Ability to act with integrity and maintain confidentiality.
Skill in performing statistical and mathematical computations.
Skill in preparing presenting reviewing and analyzing insurance claims forms and reports.
Skill in providing excellent customer service.
Skill in operating business computers and office machines including in a Windows environment specifically Word Excel Access and presentation software (such as PowerPoint).
Database management skills.
Excellent telephone communication skills.

Working Conditions & Physical Demands

Typical business office setting with moderate noise level.
Non-office environment may be encountered for offsite presentations and support of company activities.
Must be able to sit for work at a computer and phone for more than 6 hours per day.
Must be able to speak clearly.
Must be able to use hands for dexterity of motion.
Frequently required to stand walk and reach with hands and arms.
Must have ability to occasionally lift 20 lbs.
Must be willing to travel as necessary which may require overnight stays.

Physical Exam

Required to successfully pass an annual physical exam to certify that the incumbent is capable of performing the physical demands of the job as described above.

Key Skills

Hp Unix
Administration & Operation
Ado
IT Security
Management Administration

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About Company

Amerind

The only 100 percent Tribally owned insurance provider based in New Mexico. AMERIND offers a comprehensive line of affordable insurance products. We provide strategic planning for tribal broadband deployment for […]

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