[Hiring] Senior Workers' Compensation Senior Claims Representative @MEM

Role Description

Are you a seasoned claims professional with a passion for navigating complex cases? MEM Insurance is seeking a Senior Claims Representative to join our Claims team. In this pivotal role, you’ll manage high-exposure workers’ compensation claims, lead investigations into coverage and fraud, and collaborate across departments to drive strategic outcomes. You’ll be a key decision-maker, a mentor to junior adjusters, and a champion of process improvement—all while ensuring exceptional service and regulatory compliance.

Essential Duties and Responsibilities:

• Claims Handling & Administration:
  • Manage highly complex claims involving significant financial exposure, legal intricacies, and extended life cycles.
  • Conduct advanced investigations into coverage and compensability, including nuanced statutory interpretations.
  • Oversee medical case management for catastrophic injuries and lifetime care needs.
  • Review and authorize large or complex medical bills, negotiating adjustments to control costs.
• Return-to-Work Management:
  • Develop comprehensive RTW strategies in collaboration with policyholders, legal counsel, and vocational consultants.
  • Ensure precision in benefit calculations for high-exposure claims, addressing tax and compliance risks.
  • Strategically deploy investigative efforts aligned with broader claims strategy.
• Claims Investigation & Loss Prevention:
  • Lead investigations into complex fraud cases and collaborate with the Special Investigations Unit.
  • Conduct subrogation analysis and negotiate with third-party insurers or attorneys for maximum recovery.
• Settlements & Negotiation:
  • Partner with legal teams to negotiate complex settlements and manage litigation processes.
  • Oversee Medicare compliance initiatives, including Medicare Set-Asides and CMS engagement.
  • Identify opportunities for structured settlements and lead negotiations.
• Reporting:
  • Produce strategic reports on high-profile claims to guide management decisions.
  • Maintain system data integrity and prepare claims for Corporate Plan of Action meetings.
• Collaboration:
  • Lead cross-departmental efforts to improve claims handling and risk management.
  • Resolve escalated customer service issues and support high-value accounts.
  • Participate in workflow improvement initiatives and committees.
• Team Leadership:
  • Mentor and coach junior and intermediate adjusters.
  • Review escalated claims and provide actionable feedback.
  • Support workforce development and succession planning.

Qualifications

• Bachelor’s degree in business or related field preferred, or equivalent industry experience.
• 7–10 years of claims handling experience, with high exposure to Workers’ Compensation.
• Associate in Claims (AIC), AIM, or CPCU designation preferred or ability to obtain.
• Texas All-Lines license preferred.
• Valid driver’s license required.

Benefits

• Health Plans: Medical, Dental, and Vision, including fertility benefits, fully paid preventative care, and adult orthodontia.
• Employer-Paid Life and Disability Benefits: Life Insurance (3x base salary), AD&D, Short and Long-term Disability.
• Wellness and Recognition Program: Employer-paid incentives for employees and spouses.
• Flexible Spending Account and Dependent Care options.
• Health Savings Account: Generous employer contribution.
• Time Away from Work: Generous PTO, 11 Holidays + 4 Early Releases, 16 Hours Volunteer Time Off, 20 Days Paid Parental Leave, Marriage, Bereavement, and Jury Duty leave.
• Employee Assistance Programs.
• 401k Retirement Plan: Employer match and profit sharing.
• Adoption Assistance and Tuition Assistance.