Job Description

Senior Claims Workers' Compensation Representative

Pasadena, CA - Hybrid/Remote

$75k-$105k - Based off of experience.

A Senior Claims Representative in Workers' Compensation is a seasoned professional responsible for managing the most complex and high-value claims. Their role involves a combination of technical expertise, leadership, and effective communication to ensure that claims are handled efficiently, compliantly, and in the best interest of all parties involved.

Duties and Responsibilities:

Handle complex workers' compensation claims from initiation to closure.
Conduct thorough investigations to determine the validity of claims.
Review and analyze claim files to ensure accuracy, completeness, and compliance with company policies and legal requirements.
Negotiate settlements with injured workers, attorneys, and other stakeholders.
Evaluate the cost-effectiveness of settlement options.
Collaborate with medical professionals to assess the medical aspects of claims.
Address and resolve disputes related to claims, including disagreements over coverage, benefits, and compensability.
Provide guidance on dispute resolution strategies.
Ensure compliance with federal and state workers' compensation laws and regulations.
Stay updated on changes in legislation that may impact claims processing.
Maintain accurate and detailed records of claims, communications, and decisions.
Generate reports on claims status, trends, and key performance indicators.
Implement and oversee quality assurance processes to ensure consistency and accuracy in claims handling.
Conduct audits of claims files for compliance and quality.
Collaborate with insurance adjusters, legal counsel, medical professionals, and other stakeholders involved in the claims process.
Investigate and detect potential instances of fraud or abuse in workers' compensation claims.
Monitor and manage the budget associated with workers' compensation claims.
Implement cost-effective strategies for claims resolution.
Contribute to the development and implementation of risk management strategies to minimize future claims and losses.

Requirments:

Must be bilingual Spanish
Must have a California Workers' Compensation License
3-5 years of worker's compensation claims experience
Experience in commercial/construction insurance is preferred.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.