Job description
Claims Specialist
Cities and Villages Mutual Insurance Company
Wauwatosa, WIAPPLY HERE
WHY JOIN THE CVMIC TEAM:
- The ability to make a difference to our municipal clients/members!
- Great variety in what you do each day
- Flexibility with your schedule, including the ability to work remotely
- A supportive team environment
- Outstanding benefits that include: Company-paid retirement contribution into a Simplified Employee Pension (SEP) Plan: 12.1% of salary, after one year of employment, Company-paid health insurance premiums, and tuition reimbursement for continued opportunities for growth and development!
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Under the general supervision of the Worker’s Compensation Claims Manager, this position is responsible for investigating, processing and adjusting worker’s compensation claims. Some travel may be required with occasional overnight stays.
Essential Duties & Responsibilities
- Reviews first report of injury forms (WC-12) and follow up with claimants, insureds, medical providers or others in a timely manner to determine compensability.
- Files required State forms in a timely and accurate manner.
- Processes new claims, sets and monitors reserves.
- Maintains up to date files and diaries on all active claims.
- Interviews, telephones, or corresponds with municipal client/member representatives, employees, and supervisors, claimants, witnesses and medical personnel; reviews medical and hospital records in a timely manner to determine compensability while maintaining required confidentiality.
- Recommends and sets up Independent Medical Evaluations, Vocational Evaluations and assigns Rehabilitation Nurses as necessary.
- Reviews and pays medical bills and indemnity benefits. Submits medical bills for third party review.
- Identifies and reports claims with re-insurance/excess insurance exposure to the carrier, Claims Manager and CEO.
- Exercises discretion within settlement authority to pay, deny or settle claims and establish reserves on claims. Exercises discretion with respect to investigating claims and processing medical bills and indemnity payments. Discretion is also required with respect to all Company procedures to allow for the flexibility needed to process claims properly and in a timely manner.
- Recommends litigation when settlement cannot be negotiated; Oversees litigation on contested cases.
- Assigns work, provides oversight and reviews files of Claims Assistants and Med-Only Claims Specialist.
- Monitors claims to identify and follow-up on subrogation opportunities.
Other Duties & Responsibilities
- Attends Administrative hearings.
- Conducts claim file review with municipal clients/members.
- Provides Worker’s Compensation training for municipal clients/members as needed.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Associate’s degree (A. A.) or equivalent from two-year college or technical school;
- Three to five years related experience and/or training; or equivalent combination of education and experience.
Knowledge, Skills & Abilities
Knowledge of:
- The principles and practices of worker’s compensation claims handling.
- Wisconsin Worker’s Compensation Act, Administrative Code and case law.
- Duty disability and long term disability benefits, including 40.63 and 40.65.
- Claims software, Outlook, Excel and Microsoft Word or similar business software.
- American’s with Disabilities Act (ADA), Family & Medical Leave Act (FMLA), and Medicare set aside laws.
Ability to:
- Accurately calculate and verify indemnity payments as required by the Worker’s Compensation Act and Wisconsin Administrative Code.
- Handle sensitive situations in a professional manner that reflects favorably upon the municipal client/member and Company.
- Communicate professionally, timely and effectively both orally and in writing.
- Interact effectively with others inside and outside the organization.
- Accurately and efficiently read, analyze, and interpret general business periodicals, medical reports, legal reports, and governmental regulations.
- Accurately and efficiently write reports and business correspondence..
- Effectively and professionally present information and respond to questions from clients, claimants, medical service providers, attorneys and representatives from governmental agencies.
Certificates, Licenses, Registrations
- Must possess and maintain a valid Wisconsin driver’s license during employment.
- Must be able to provide an automobile with liability insurance limits acceptable to the company.
\* T he salary range represents the 2025 range, not the hiring range.
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