Claims Representative II

Pinnacol Assurance does just one thing, and does it better than anyone: provide caring workers’

Compensation

protection to Colorado employers and employees. And while we may be a little biased, we believe that our work shapes communities and changes lives. We have big hearts and love big ideas.

We’ve been around for more than 100 years, but don’t let that fool you. Pinnacol is committed to taking care of Colorado employers and workers in the most innovative ways. We celebrate continuous improvement, new ideas, compassion, teamwork, integrity and excellence.

Act. Proactively manage open claims as required by Company best practices, including expedient and cost effective medical case management, disability management, and litigation management, as well as identification, investigation, management and resolution of potential adverse claim development, including prior injuries, comorbid and pre-existing medical conditions, migrating body parts, worsening medical conditions and delayed recovery, change of physician requests, multiple claims, multiple jobs, subrogation, penalties and offsets. Coordinate and oversee all necessary resources on a timely basis for optimal claim management, action plan development and claim resolution, including other claims team members, Claims Lead, Claims Owners, Underwriter, Business Director, Legal resources, Return-to-Work Consultant, Safety Consultant, Medical Case Manager, Utilization Review, MedPay Liaison, Provider Relations Specialist and Claims Director.

Proactively communicate and correspond with stakeholders as needed to manage and resolve open claims, including but not limited to policyholders, injured workers, agents, medical providers, service vendors and resources, attorneys and regulatory agency representatives. Correspondence includes phone, email, fax, possible face to face meetings, and accurate claim documentation. Facilitate early return to work for injured workers by working with policyholder, and Return-to-Work Consultant if needed.

Act. Evaluate claims for settlement by determining most likely medical path and return to work possibilities.

What You’Ll Do

: Work with team members to strategically and proactively manage indemnity claims and claim-related issues to the most expedient, cost effective resolution; provide quality customer service to all stakeholders which includes proactive communication and follow through at all times. Identify claims that need complex management and work with team members to resolve concerns or escalate to the appropriate level or secure appropriate resources. Must demonstrate consistent follow through with all stakeholders to ensure efficient and effective resolution of each issue and claim.

What you can expect: Contact stakeholders as required by Company best practices on incoming claims to promptly investigate circumstances of accident and injury, investigate and determine compensability, and identify and address red flag issues, including late reporting, pre-existing medical issues, designated medical provider process and referral issues, medical treatment issues, legal issues, and potential subrogation and penalty issues. Be able to manage the relationships with your stakeholders in order to obtain timely and accurate information in order to complete this process. Effectively and proactively communicate your decisions and evaluate for customer understanding.

Benefits

including permanent impairment. Negotiate settlement with the help of in house or external legal counsel. Negotiate settlement directly with injured workers or their counsel.