ESIS Senior Claims Representative, WC

JOB DESCRIPTION

ESIS Senior Claims Representative, WC , Cheektowaga, NY

Under the direction of the Claims Team Leader, the Senior Workers' Compensation Claim Representative investigates, evaluates, and resolves claims in a timely, fair, and consistent manner, in accordance with established best practices and applicable policy provisions.

Duties may include, but are not limited to:


* Receive and manage new claim assignments.


* Review claim and policy information to establish the basis for investigation and determine the extent of the policy's obligation to the insured, depending on the line of business.


* Contact, interview, and obtain statements, recorded or in person, from insureds, claimants, witnesses, physicians, attorneys, police officers, and others to gather relevant claim information.


* Arrange surveys and expert evaluations, as appropriate.


* Evaluate facts obtained through investigation to determine liability, if any, and the company's obligation to the insured under the policy contract.


* Prepare reports related to investigations, settlements, claim denials, and evaluations of involved parties.


* Set reserves within authority limits and recommend reserve changes to the Team Leader.


* Review claim progress and status with the Team Leader and discuss issues and recommended corrective actions.


* Manage litigation files in a timely and appropriate manner.


* Assist the Team Leader in developing methods and process improvements for claims handling.


* Resolve claims in a timely and fair manner.


* Obtain releases, proofs of loss, or compensation agreements and issue company drafts for claim and expense payments.


* Inform claimants, insureds, customers, agents, or attorneys of claim denials when applicable.


* Assist the Team Leader and company attorneys in preparing cases for trial by arranging witness attendance and taking statements, while continuing efforts to resolve claims before trial.


* Refer claims to subrogation, as appropriate.


* Participate in claim file reviews and audits with customers, insureds, and brokers, as needed.


* Administer benefits in a timely and appropriate manner and maintain control of the claim resolution process to help minimize current exposure and future risk.


* Establish and maintain effective working relationships with agents, underwriters, insureds, experts, and other stakeholders.

Depending on the line of business, other duties may include:


* Maintaining system logs


* Investigating compensability and benefit entitlement


* Reviewing and approving medical bill payments or forwarding them for outside review, as necessary


* Managing vocational rehabilitation

QUALIFICATIONS

Experience & Education


* Bachelor's degree or equivalent work experience required; additional education, such as an MBA, is preferred.


* Strong technical knowledge and proficiency in workers' compensation claims, suppo...