Company Name: Cities and Villages Mutual Insurance Company
Job Title: Claims Specialist
Location: Wauwatosa, WI
Summary of Job
Under the general supervision of the Worker's Compensation Claims Manager, this position is responsible for investigating, processing and adjusting worker's compensation claims. Some travel may be required with occasional overnight stays.
Essential Duties & Responsibilities
- Reviews first report of injury forms (WC-12) and follow up with claimants, insureds, medical providers or others in a timely manner to determine compensability.
- Files required State forms in a timely and accurate manner.
- Processes new claims, sets and monitors reserves.
- Interviews, telephones, or corresponds with member representatives, member employees, supervisors, claimants, witnesses, and medical personnel; reviews medical and hospital records in a timely manner to determine compensability while maintaining required confidentiality.
- Sets up Independent Medical Evaluations, Vocational Evaluations and assigns Rehabilitation Nurses as necessary.
- Performs field investigations or assigns to an outside adjuster for field investigations when necessary.
- Reviews and pays medical bills and indemnity benefits. Submits medical bills for third party review.
- Identifies and reports claims with re-insurance/excess insurance exposure to the carrier, Claims Manager, and Chief Executive Officer (CEO).
- Exercises discretion within settlement authority to pay, deny or settle claims and establish reserves on claims. Exercises discretion with respect to investigating claims and processing medical bills and indemnity payments. Discretion is also required with respect to all Company procedures to allow for the flexibility needed to process claims properly and in a timely manner.
- Maintains files on a current basis on claims system.
- Maintains up to date diary on all active claims.
- Develops litigation plans and oversees the litigation on contested cases.
- Assigns work and provides oversight of Claims Assistants.
- Prepares and submits timely and accurate information to the Worker's Compensation Department.
- Recommends and schedules independent medical exams and surveillance.
- Recommends litigation when settlement cannot be negotiated.
- Monitors claims to identify and follow up on subrogation opportunities.
- Schedules and prepares Worker's Compensation User's Group meetings.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Associate's degree (A. A.) or equivalent from two-year college or technical school;
- Three to five years related experience and/or training; or equivalent combination of education and experience.
Knowledge, Skills & Abilities
- Knowledge of the principles and practices of worker's compensation claims handling.
- Knowledge of Wisconsin Worker's Compensation Act, Administrative Code and case law.
- Knowledge of claims software, Outlook, Excel and Microsoft Word or similar business software.
- Ability to accurately calculate and verify indemnity payments as required by the Worker's Compensation Act and Wisconsin Administrative Code.
- Ability to handle sensitive situations in a professional manner that reflects favorably upon the member and Company.
- Ability to communicate professionally, timely and effectively both orally and in writing.
- Ability to interact effectively with others inside and outside the organization.
- Ability to accurately and efficiently read, analyze, and interpret general business periodicals, medical reports, legal reports, and governmental regulations.
- Ability to accurately and efficiently write reports and business correspondence.
- Ability to effectively and professionally present information and respond to questions from clients, claimants, medical service providers, attorneys and representatives from governmental agencies.
We Make it Easy
• Applying takes less than 2 minutes. No passwords or accounts to register or sign-in for.
• You are hired directly by the company – MRA does not make hiring decisions.
Founded in 1901, MRA is a nonprofit employer association that serves more than 4,000 employers, covering more than one million employees.
As one of the largest employer associations in the nation, MRA helps its member organizations thrive by offering the most comprehensive assortment of HR services, information, education, and resources to help build successful workplaces and a powerful workforce.
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