Insurance Claims Representative: Workers' Compensation

Description

Key Responsibilities

• Serve as the main liaison between insured clients and workers’ compensation insurance carriers.
• Facilitate timely communication regarding claim status, settlement decisions and action plans.
• Coordinate with adjusters, medical case managers, attorneys, agents, account manager and other involved parties to promote efficient claim resolution.
• Communicate carrier recommendations and decisions to clients in a clear, professional manner.

• Monitor open claims for assigned accounts to ensure proper handling, timely deadlines and compliance with applicable regulations.
• Review loss runs and document for accuracy and new claims; identify trends, anomalies, and opportunities for improvement.
• Advocate on behalf of insured clients to ensure appropriate medical management and expeditious claim resolution.
• Collaborate with clients to implement return-to-work programs and cost-containment strategies.
• Schedule and conduct Zoom, Teams, or telephonic meetings with carriers and other involved parties to advocate on behalf of insured clients and injured workers regarding claim status, legal issues, medical treatment concerns, and/or inefficiencies impacting timely resolution or closure of claims.

• Provide expert guidance to clients regarding workers’ compensation reporting, claim filing and documentation requirements.
• Assist clients with claim submissions and ensure all necessary information is provided to carriers.
• Participate in client claim review meetings, stewardship presentations, and renewal strategy sessions.
• Educate clients on workers’ compensation best practices, workplace safety, injury prevention and effective claims management.
• Collaborate with the company’s Safety Department to identify injury trends and develop strategies or training initiatives to reduce future workplace incidents. 
• Provide workers’ compensation knowledge, insights, and recommendations to insured accounts not currently enrolled in the Claims Watch value added service, to enhance their understanding and engagement with claims management practices.

• Maintain accurate and detailed claim documentation within the brokerage’s claims tracking system.
• Prepare customized reports summarizing claim performance, open claim counts and cost trends.
• Analyze loss data to identify recurring issues and recommend targeted interventions.
• Provide internal management with reports to assist in account servicing and retention efforts.
• Maintain workflow spreadsheets to track individual and departmental productivity, and to provide data insights for management reporting and performance analysis.
• Complete experience modification projections and analysis to provide clients with a prognosis of their potential premium for the upcoming policy period.
• Monitor WCIRB notice alerts for experience modification initial worksheets or revisions, and communicate relevant updates or impacts to clients and internal agents and account managers.
• Prepare and provide insured with quarterly reports including claim status reports, loss runs new claims, no claim notices and claim closure reports, to ensure clients remain informed of claim activity and closed claims.

• Conduct themselves in a professional and respectful manner at all times.
• Communicate appropriately and refrain from using offensive or disrespectful language.
• Comply with all assigned tasks and directives from management.
• Attend all mandatory meetings and participate actively in team and company activities.
• Demonstrate a positive, professional attitude and contribute constructively to the team environment.
• Practice strict confidentiality at all times regarding company information, client data, and sensitive claim information.

Skills, Knowledge and Expertise

• Associate’s or Bachelor’s degree in Business Administration, Risk Management, or a related field preferred.
• Minimum of 2–5 years of experience in workers’ compensation claims handling, carrier relations, or client advocacy within a brokerage, carrier, or TPA setting.
• Comprehensive understanding of state workers’ compensation statutes, medical case management practices, legal terminology and claims processes.

• Strong verbal and written communication skills with a client-service mindset, ability to resolve complaints and disputes.
• Proven ability to build and maintain effective professional relationships.
• Exceptional analytical, organizational, and problem-solving abilities.
• Proficiency with Microsoft Office Suite (Excel, Word, PowerPoint) and claims management or CRM software.
• Ability to manage multiple priorities and deliver results in a fast-paced environment.

• Associate in Claims (AIC), Workers’ Compensation Claims Professional (WCCP), or similar industry designation.
• State adjuster license or Self-Insurance Administrator (SIP) certificate (if required by jurisdiction).