ESIS Claims Representative, WC

ESIS Claims Representative, WC

Under direct supervision initially, performs customer service and claims functions while training to become a claims representative. Gains exposure to all facets of a professional claims representative role through classroom and hands-on learning. As training progresses, will be assigned a caseload.

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.
• 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.