CLAIMS REPRESENTATIVE

Summary of role:

Responsible for managing workers’ compensation claims by investigating reported incidents, determining compensability, coordinating medical and disability management, evaluating claim exposure, and ensuring compliance with state laws and reporting requirements. This role partners with injured employees, store personnel, medical providers, attorneys, case managers, and other service providers to support return-to-work efforts, manage benefits, control claim costs, develop strategic resolution plans, and maintain compliance with applicable workers’ compensation regulations and licensing requirements.

• Conduct interviews with injured employees, store personnel, and medical care providers within 24 hours of receiving a reported incident. Utilize complex problem-solving, critical-thinking, and organizational skills to evaluate compensability and effectively manage claim assignments. Maintain communication with appropriate parties throughout the life of the claim to support proper medical and disability management and resolution. 20%

• Utilize professional experience and investigative skills to evaluate claim exposure and develop action plans related to medical management, disability management, and claim resolution. 20%

• Proactively coordinate and communicate with physicians, injured employees, and store personnel regarding light-duty or full-duty return-to-work opportunities, payment of appropriate benefits, and utilization of in-house and field nurse resources for medical and disability management. 15%

• Evaluate requests for medical care to determine causation and relatedness in compliance with state requirements. Timely assess and pay medical and indemnity benefits in accordance with applicable laws and complete all required state reporting. 15%

• Coordinate and communicate with service providers, including defense attorneys, medical case managers, and private investigators, to minimize claim expenses and maximize outcomes. 10%

• Develop and maintain a proactive strategic action plan throughout the life of each claim. Resolve claims efficiently and provide recommendations for claim resolution in accordance with best practices and state requirements. 10%

• Maintain working knowledge of multiple state workers’ compensation laws and regulations and maintain all required state licensing. 10%