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9451
CLAIMS REPRESENTATIVE 1
Nature of Work
Under direct supervision, reviews,
evaluates and processes an assigned caseload of Workers
Compensation claims. Responsible for a caseload involving
primarily unprotested no lost time and lost time claims with less
than four weeks of indemnity benefits. Performs related work as
required.
Distinguishing Characteristics
The Claims Representative I
is distinguished from the Claims Representative 2 by the
responsibility of claims assigned. The Claims Representative I
is responsible for a caseload involving primarily unprotested no
lost time and lost time claims with less than four weeks of
indemnity benefits.
Examples of Work
Analyzes assigned new claims and reopening applications;
determines applicability of coverage and chargeability.
Contacts claimants, employers, physicians, witnesses, and
other agents to gather and verify information; secures
salary information and determines compensation rate.
Determines claim compensability.
Requests treatment plans from physicians and other clinical
providers.
Reviews requests for treatment, change of physicians, payment
of medical expenses and payment of indemnity benefits.
Requests independent medical examinations; reviews independent
medical examination reports and determines appropriateness
of recommendations based upon current accepted guidelines.
Explains decisions and appeal rights to physicians, attorneys,
government officials, other clinical providers and other
interested parties.
Issues protestable and non-protestable orders related to
claims.
Maintains active claim diaries and file notes.
Knowledge, Skills and Abilities
Ability to learn West Virginia Workers Compensation statute,
rules, regulations, policies and procedures.
Ability to learn West Virginia court precedent setting
decisions and application of rulings.
Ability to learn medical terminology, anatomy, body systems,
and treatment protocol.
Ability to communicate effectively, both orally and in
writing.
Ability to use medical treatment guidelines in processing
claims.
Ability to establish and maintain effective working
relationships with the public, providers and other
employees.
Ability to operate a personal computer, recording equipment
and other office equipment.
Minimum Qualifications
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Training:
Graduation from a standard four-year high school or
the equivalent.
Experience:
Two years of full-time or equivalent part-time
paid experience in the investigation,
evaluation, and settlement of workers
compensation claims with an insurance
company, self-insured or third party
administrator, or as a claims technician assigned to a
claims team, Office of Claims Management, Workers'
Compensation; OR three years full-time or equivalent part
time paid experience working with insurance claims
or in claims/insurance adjusting, claims
investigation, paramedic or medical assistant field.
Substitution:
Course work from an accredited four-year
college or university, or related business school or
vocational training may substitute through an established
formula on a year-for-year basis for the experience OR
Successful completion of the AIC course of study through
the Insurance Institute of America, certification as a
Certified Case Manager (CCM) or Certified Insurance
Rehabilitation Specialist (CIRS) may substitute for one
year of the required experience.
Established: 3/21/96
Effective:
4/01/96