ESIS Senior Claims Representative, WC

JOB DESCRIPTION

The ESIS Senior California Claim Representative, under the direction of the Claims Team Leader, investigates and settles claims promptly, equitably and within established best practices guidelines.

Duties may include but are not limited to:


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

As a Senior Claim Representative, candidate will be responsible for more complex and intricate, requiring an advanced skillset.


* Communication: Serve as the primary point of contact for injured workers, employers, medical providers, and other stakeholders, providing clear and professional communication throughout the claims process.


* Investigation: Conduct thorough investigations of claims, 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 the facts of the case and applicable laws.


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


* Cost Control: Monitor and manage claim costs, including medical expenses, indemnity payments, and legal fees, while ensuring appropriate reserves are established and maintained.


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


* Customer Service: Provide exceptional service to clients 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 of experience handling workers' compensation claims; prior experience with ESIS or similar third-party administrators is a plus.


* Jurisdiction & Licensing: Knowledge of California Workers Compensation and active adjuster license or ability to obtain licensure within a specified timeframe.


* Compliance: Ensures compliance with all legal, regulatory and company-specific requirements


* Quality Review Performance: Achieves strong quality review scores by adhering to established high standard procedures


* ESIS/Client/Carrier Requirements: Follows ESIS Best Practices; adheres to client and carrier guidelines and requirements to ensure accuracy in documentation, claims handling and service delivery


* Skills:
+ Strong analytical and problem-solving abilities.
+ Excellent verbal and written communication skills.
+ Proficiency in claims management systems and Microsoft Office Suite.
+ Ability to manage multiple priorities and meet deadlines in...