Senior Work Comp Claims Representative
SFM – The Work Comp Experts
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SFM is unique in that we are small enough that your voice is heard, but has all the benefits and perks of a larger employer. We value your opinion, help you reach your goals, and make it easy for you to maintain work-life balance. Find out why our employees rate us a top employer and choose to stay and grow with us. Find out why SFM employees have stuck around for 30+ years! Visit our careers page to learn more about working at SFM.
Since 1983, our mission has been to be the workers’ compensation partner of choice for agents, employers and their workers. In that time, we’ve expanded to a little over 20,000 customers in the Midwest and grown our offerings to include vocational rehabilitation, safe patient handling, loss prevention, medical services and more. Though much has changed through the years, our focus continues to be unrivaled customer service, safety, and providing better outcomes for employers and injured workers.
As Sr. Work Comp Claims Rep, you will investigate and manage claims for work comp benefits in a professional, prompt and effective manner, while following state workers’ compensation statutes, case law, client servicing instructions and Company best practices. Cases are resolved in a timely, strategic, and equitable fashion. You will communicate both orally and in writing with a variety of people. At SFM, you will work in a multi-functional team, so collaboration is key to being successful in this role. That multi-functional team is what makes SFM different from other companies.
- Makes timely contact with all parties to a claim to gather necessary information to determine liability and fulfill regulatory, contractual and internal reporting requirements. Applies the workers’ compensation statute and case law to facts to determine compensability. Uses internal resources as required by company best practices or client servicing instructions for questionable compensability decisions and subrogation or fraud issues.
- Sets expectations with the injured worker and employer of wellness, stay-at-work, or return-to-work, and importance of ongoing communication between all parties. Proactively involves strategic business partners as needed, such as, legal, rehab services, case managers to assist with return-to-work or stay-at-work.
- Authorizes payment of medical and wage loss benefits within payment authority.
- Assigns, directs, and manages medical, rehabilitation, investigative and legal services pursuant to the respective business procedures, and or client service instructions and applicable state law. This includes clear documentation in claim comments of facts, issues and plans.
- Attends outside appointments, as needed. Maintains appropriate interactions with persons both within the organization and externally. If needed, independently conducts field visits with policyholders, agents and injured workers.
- Handles fatalities and catastrophic cases, such as paraplegia, quadriplegia, catastrophic head injury, major amputation, in the acute stage, and post-acute when appropriate, with guidance from technical experts and claims specialists.
- Establishes initial and ongoing case reserves within authority level that accurately reflect file exposure in accordance with Company reserving guidelines relating to qualitative analysis and timing and/or client service instructions. Recommends reserves for cases that exceed authority level.
- Communicates and educates the employer on case exposure/reserves and how to mitigate the exposure. Communicates and partners with the reinsurer regarding case exposure/reserves, high expense items and issues which impact future costs.
- Provides and documents strategy to bring cases to resolution per the respective business’s best practices, procedures and philosophy. This is evidenced by documenting files in claim comments with 1) timely action plans; 2) pertinent facts and issues for roundtable discussions; and 3) analysis of settlement exposure, including spreadsheets or actuarial advice when appropriate.
- Identifies, analyzes and resolves the majority of payment changes and errors on files. When unable to resolve, actively seeks out and works with Claims Technical to learn for future application.
- Manages data timely and accurately on files to be in compliance with state regulatory reporting requirements, rating bureau reporting mandates and internal data needs.
- Provides technical and marketing services in order to maintain agency and policyholder/client relationships so as to achieve success with new business goals, retention of renewals and loss experience consistent with team and company goals.
- Learns new jurisdictions when asked.
We’re looking for
Education and Experience
- Bachelor’s degree preferred.
- Four or more years of workers compensation lost time experience.
- Pursuit or attainment of a professional insurance designations (CPCU, ARM) preferred.
Knowledge and Skills
- Knowledgeable of state applicable Workers’ Compensation Act and its application to claims administration.
- Knowledge and skills in state regulatory reporting.
- Strong knowledge of medical terminology, anatomy and procedures.
- Awareness of related disability benefits.
- Understanding of insurance finance.
- Excellent customer service and interpersonal skills.
- Outstanding oral and written communication skills.
- Proven ability to effectively interact with a diverse group of customers and business units.
- Ability to assimilate, understand and analyze information from a variety of sources.
- Strong math skills.
- Strong skills in investigating, negotiating and settling claims.
- Strong problem-solving and decision-making skills.
- Strong computer skills (preferable in a Windows environment).
- Effective prioritization, organization and time management skills.
- Demonstrates positive teaming skills focused on team results.
Work takes place in a semi paperless environment within an office, using standard office equipment such as computers, phones, photocopies, which requires being stationary for extended periods of time. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms and work with close vision. This position requires the ability to occasionally lift office products and supplies, up to 20 pounds. Work is performed indoors with little to no exposure to extreme outdoor weather conditions.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Watch videos to learn more about SFM’s careers and culture. https://www.youtube.com/watch?v=g7VkUazIOXA
SFM Mutual Insurance Company and each of its parent companies, subsidiaries and/or affiliated companies are Equal Opportunity/Affirmative Action Employers. All employment decisions are made without regard to race, color, religion, sex, national origin, age, sexual orientation, marital, familial, or veteran status, medical condition or disability, or any other legally protected classification.
SFM Companies, EEO/AA Employers. SFM is a participant of E-Verify. Applicants have rights under Federal Employment Laws.