Senior Workers' Compensation Senior Claims Representative
Location
United States
Posted
22 days ago
Salary
$72.8K - $109.2K / year
Seniority
Senior
No structured requirement data.
Job Description
Senior Workers' Compensation Senior Claims Representative
MEM
Role Description Are you a seasoned claims professional with a passion for navigating complex cases? MEM Insurance is seeking a Senior Claims Representative to join our Claims team. In this pivotal role, you’ll manage high-exposure workers’ compensation claims, lead investigations into coverage and fraud, and collaborate across departments to drive strategic outcomes. You’ll be a key decision-maker, a mentor to junior adjusters, and a champion of process improvement—all while ensuring exceptional service and regulatory compliance. Essential Duties and Responsibilities: - Claims Handling & Administration: - Manage highly complex claims involving significant financial exposure, legal intricacies, and extended life cycles. - Conduct advanced investigations into coverage and compensability, including nuanced statutory interpretations. - Oversee medical case management for catastrophic injuries and lifetime care needs. - Review and authorize large or complex medical bills, negotiating adjustments to control costs. - Return-to-Work Management: - Develop comprehensive RTW strategies in collaboration with policyholders, legal counsel, and vocational consultants. - Ensure precision in benefit calculations for high-exposure claims, addressing tax and compliance risks. - Strategically deploy investigative efforts aligned with broader claims strategy. - Claims Investigation & Loss Prevention: - Lead investigations into complex fraud cases and collaborate with the Special Investigations Unit. - Conduct subrogation analysis and negotiate with third-party insurers or attorneys for maximum recovery. - Settlements & Negotiation: - Partner with legal teams to negotiate complex settlements and manage litigation processes. - Oversee Medicare compliance initiatives, including Medicare Set-Asides and CMS engagement. - Identify opportunities for structured settlements and lead negotiations. - Reporting: - Produce strategic reports on high-profile claims to guide management decisions. - Maintain system data integrity and prepare claims for Corporate Plan of Action meetings. - Collaboration: - Lead cross-departmental efforts to improve claims handling and risk management. - Resolve escalated customer service issues and support high-value accounts. - Participate in workflow improvement initiatives and committees. - Team Leadership: - Mentor and coach junior and intermediate adjusters. - Review escalated claims and provide actionable feedback. - Support workforce development and succession planning. Qualifications - Bachelor’s degree in business or related field preferred, or equivalent industry experience. - 7–10 years of claims handling experience, with high exposure to Workers’ Compensation. - Associate in Claims (AIC), AIM, or CPCU designation preferred or ability to obtain. - Texas All-Lines license preferred. - Valid driver’s license required. Benefits - Health Plans: Medical, Dental, and Vision, including fertility benefits, fully paid preventative care, and adult orthodontia. - 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 spouses. - Flexible Spending Account and Dependent Care options. - Health Savings Account: Generous employer contribution. - 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.
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