Remote Claims Lead Representative

Company Overview

The Enlyte Family of Businesses

Mitchell | Genex | Coventry

Enlyte is the parent brand of Mitchell, Genex and Coventry, an organization unlike any other in the Property & Casualty industry, bringing together three great businesses with a shared vision of using technology innovation, clinical services and network solutions to help our customers and the people they serve. Our suite of products and services enable our employees to help people recover from challenging life events, while providing opportunities for meaningful impact and career growth.


Job Description

The Claims Lead Representative position is part of the Qual-Lynx claims department that supports the unit with clerical work and data entry.

This is a remote position with a preference that the Representative reside in the eastern time zone. This individual must have workers comp experience in New Jersey.

Investigates, evaluates, and resolves assigned Workers’ Compensation claims of a more complex or litigated nature in a timely manner in accordance with legal statutes, policy provisions and company guidelines.

  • Evaluate claimant eligibility; communicate with attending physician, employer and injured worker.
  • Work with both the claimant and their physician to medically manage the claim, from initial medical treatment to reviewing and evaluating ongoing treatment and related information.
  • Work directly with employers to facilitate a return to work, either on a full-time or modified duty basis.
  • Confirm coverage and applicable insurance policy or coverage document and statutory requirements.
  • Identify potential for third party recovery, including subrogation, Second Injury Fund or other fund involvement (when applicable) and excess or reinsurance reimbursement. Pursue the process of reimbursement and complete posting of recovery to the claim file, where appropriate.
  • Identify potential for disability or pension credits or offsets and apply same where appropriate.
  • Ensure timely denial or payment of benefits in accordance with jurisdictional requirements.
  • Establish claim reserve levels by estimating the potential exposure of each assigned claim, establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure.
  • Establish compensability status through case investigation and evaluation and application of jurisdictional statutes and laws.
  • Manage diary in accordance with Best Practices and complete tasks to ensure that cases move to the best financial outcome and timely resolution.
  • Where litigation is filed, evaluate exposure and work with defense counsel to establish strong defenses, prepare litigation plan of action, set legal reserve and manage litigation over life of claim.
  • Close all files as appropriate in a timely and complete manner.
  • Maintain closing ratio as directed by management team.
  • Oversee and coordinate medical treatment for injured employees and provide information to treating physicians regarding employees’ medical history, health issues, and job requirements; provide direction to assigned nurse case manager where applicable.
  • Complete PARs (payment authorization request) when applicable.
  • Comply with all excess and reinsurance reporting requirements; manage self-insured retention reporting.
  • Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account-related issues.
  • Provide a high degree of customer service to clients, including face to face interactions during claim reviews, meetings and similar account-specific sessions.
  • Perform other duties as required.

Qualifications

  • High School diploma required;
  • Associate’s or Bachelor’s degree preferred, or five or more years of equivalent work experience required in an insurance, medical/health or legal related industry;
  • At least 4 years of experience handling workers’ compensation claims required; more experience may be required depending upon complexity of claim pending.
  • Completion of Workers’ Compensation training courses internally and/or externally in all significant areas affecting Workers’ Compensation claims handling and practices a plus
  • Workers’ Compensation licenses, certifications, awards preferred.

SKILLS: Proficient with MS Excel and Word; computer experience with related claims software;  excellent verbal and written communication skills; proven interpersonal skills capable of dealing with all levels of personnel; exceptional ability to multi-task; excellent  negotiation skills; superior organizational and decision making skills; customer-focused orientation; strong analytical and strategizing skills; expertise in  Workers’ Compensation and related claims handling practices and ability to apply same; deep knowledge of client and carrier claims procedures; significant understanding of self-insured retention, excess and reinsurance reporting; fluent in medical terminology and medical/injury treatments. 


Benefits

We’re committed to supporting your ultimate well-being through our total compensation package offerings that support your health, wealth and self. These offerings include Medical, Dental, Vision, Health Savings Accounts / Flexible Spending Accounts, Life and AD&D Insurance, 401(k), Tuition Reimbursement, and an array of resources that encourage a lifetime of healthier living.   The Company is an equal opportunity employer, values the diversity of our workforce and the knowledge of our people. The Company does not discriminate against an applicant or employee on the basis of race, color, religion, national origin, ancestry, sex/gender, age, physical or mental disability, military or veteran status, genetic information, sexual orientation, gender identity, gender expression, marital status, or any other characteristic protected by applicable federal, state or local law.   #LI-CF1
Company
Coventry
Posted
01/01/2022
Type
Full time
Salary Range
$34,000.00 - 49,000.00
per Year
Salary range estimated by
Location
New Brunswick, NJ 08933, US
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