Workers Compensation Claims Representative

Salary/Wage:USD 37,000.00 /year Status:Full Time, Employee Job Category:Accounting/Finance/Insurance Company:Sentry Insurance Contact:Barb Wilkin Email:Apply by Email Reference Code:BW: MA Workers Compensation Claims Representative Responsibilities:The Claim Service Center (CSC) is responsible for the administration of claims, with claim units handling specific insurance lines i.e., workers' compensation, liability, material damage, property, subrogation, medical/dental, disability/life, etc.  The claim units investigate, evaluate and settle claims in an equitable manner, serving the interests of the Company, policyholder and claimant while providing superior customer service. Receives claim assignments from manager and directly from the claim system.  Verifies coverages and investigates losses by gathering pertinent information. Takes recorded statements, obtains pertinent information i.e., police and medical reports, appraisals, estimates, photographs, degree of disability, rehabilitation potential, etc., and evaluates damages/eligibility for benefits, determines liability and sets reserves. Evaluates claims and charges submitted by insureds and medical providers to determine eligibility for benefits, checking for misrepresentation, preexisting conditions and mandated state benefits if applicable.  Documents all decisions, correspondence, reports and discussions that occur during the investigation.  Confers with higher level technical claim personnel for guidance and direction to ensure the file is handled properly.  Completes claim by evaluating the loss and settling the claim.  Denies coverage where coverage does not exist.  Determines if subrogation exists and takes steps necessary for recovery.  Within assigned authority limits, settles and pays claim.  Coordinates the payment of benefits with other insurance carriers if applicable.  Monitors claim files during initial and residual periods to ensure file currency. Refers the payment or denial of claims that exceed assigned authorization limits to Senior Claim Representative or Claim Manager with settlement recommendation.  Detects potential problems or trends that require additional review, investigation or research and refers to Senior Claim Representative or Claim Manager for resolution. Works closely with health facility, repair facility and/or contractors to facilitate necessary services or repair work.  Advises the Claim Department of any special problems i.e., questionable repair shops.  Notifies Underwriting of any adverse findings on a particular risk.  Accurately codes data submitted to outside agencies or other Sentry functions. In litigation situations, provides pertinent background information to legal counsel and assists as possible in reaching an in-court or out-of-court settlement.  Participates in administering fraud control procedures, evaluating and preparing reports, and drafting responses to formal complaints. Contacts may include policyholders, claimants, attorneys, other insurance carriers, state insurance departments, medical providers, employers, glass facilities, mechanics, police departments, insurance agents, brokers, appraisers and other internal claim, sales, underwriting or accounting staff.Qualifications:Bachelors Degree or equivalent work experience. 0-2 years of related work experience. Knowledge of insurance policies and coverages, claim payment procedures, and familiarity with medical terminology preferred. Previous insurance experience and/or coursework beneficial. Possess analytical abilities to review, exercise judgment, and evaluate claims to make sound decisions. Able to review and interpret complex and detailed documents such as contracts, medical reports and insurance regulations. Effective oral and written communication skills and human relations skills. Ability to maintain confidentiality. Personal computer and math skills beneficial. Ability to meet the travel requirements of the job to include business related assignments, with limited notice, as business needs arise.  Travel may include driving, flying or any other necessary form of transportation.Compensation and Benefits:The starting salary can be up to $37,000.00 annually depending on experience and qualifications. Sentry's excellent benefits package is designed to meet today's most important needs.  Benefits for full-time Sentry Insurance employees include: • Group Health And Dental Insurance • Prescription Eyewear Plan • Group Life Insurance • 401(K) Plan With Matching Funds • Retirement Plan • Paid-Time Off  Or Time Away From Territory Plan • Pretax Dependent Care And Health Expense Reimbursement Accounts • Student Loan Program • Credit Union • Career EducationEqual Employment OpportunityIt is our policy that there be no discrimination in employment based on race, color, national origin, religion, sex, disability, age, marital status, or sexual orientation. Equal Employment Opportunity It is our policy that there be no discrimination in employment based on race, color, national origin, religion, sex, disability, age, marital status, or sexual orientation.