ESIS Senior Claims Representative, WC

JOB DESCRIPTION

Reporting to the Claims Team Leader, the ESIS Senior Nevada Claim Representative is responsible for investigating and resolving workers' compensation claims promptly, equitably, and in accordance with established best practices.

This role handles complex and intricate claims, requiring advanced expertise and judgment.

Key Responsibilities:


* Claims Management:
Investigate, evaluate, and manage workers' compensation claims from initiation to resolution, ensuring compliance with relevant laws, regulations, and company policies.

Handle more complex claims requiring advanced skills and experience.


* Communication:
Serve as the primary contact for injured workers, employers, medical providers, and other stakeholders.

Provide clear, professional, and timely communication throughout the claims process.


* Investigation:
Conduct thorough investigations, including gathering statements, reviewing medical records, and analyzing accident reports to determine compensability and liability.


* Decision-Making:
Make timely and accurate decisions regarding claim acceptance, denial, or settlement based on case facts and applicable laws.


* Documentation:
Maintain organized and detailed claim files, documenting all activities, communications, and decisions within the claims management system.


* Cost Control:
Monitor and manage claim costs, including medical expenses, indemnity payments, and legal fees.

Ensure appropriate reserves are established and maintained.


* Compliance:
Ensure adherence to state-specific workers' compensation laws, regulations, and reporting requirements.


* Customer Service:
Provide exceptional service by addressing inquiries, resolving issues, and delivering timely updates on claim status.


* Collaboration:
Work closely with internal teams, including legal, medical, and risk management professionals, to achieve optimal claim outcomes.

QUALIFICATIONS



* Experience:
+ Minimum of 3-5 years handling workers' compensation claims.
+ Prior experience with ESIS or similar third-party administrators is preferred.


* Jurisdiction & Licensing:
+ Knowledge of Nevada Workers' Compensation regulations.
+ Active adjuster license or ability to obtain licensure within a specified timeframe.


* Compliance:
+ Ensure compliance with all legal, regulatory, and company-specific requirements.


* Quality Review Performance:
+ Achieve strong quality review scores by consistently following established high-standard procedures.


* ESIS/Client/Carrier Requirements:
+ Follow ESIS Best Practices.
+ Adhere to client and carrier guidelines to ensure accuracy in documentation, claims handling, and service delivery.


* Skills:
+ Strong analytical and problem-solving skills.
+ Excellent verbal and written communication abilities.
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