Job Type
Full-time
Description
Are you a detail-oriented professional with a passion for helping others and navigating complex situations? MEM Insurance is seeking a Claims Representative to join our collaborative and mission-driven Claims team.
In this role, you’ll manage a caseload of moderately complex workers’ compensation claims, ensuring quality care for injured workers while protecting the financial integrity of our policyholders. You’ll work closely with internal teams, policyholders, and external partners to investigate claims, develop return-to-work strategies, and negotiate fair settlements. If you thrive in a fast-paced environment and are committed to making a meaningful impact, we’d love to hear from you.
Essential Duties And Responsibilities
• Investigate and manage moderately complex workers’ compensation claims, ensuring compliance with state laws and MEM guidelines.
• Analyze statements and records to determine compensability and communicate findings to stakeholders.
• Collaborate with Nurse Case Managers and external vendors to oversee medical case management, including lifetime care planning and permanent restrictions.
• Develop tailored Return-to-Work (RTW) strategies in partnership with policyholders, ensuring accommodations align with medical restrictions.
• Calculate and issue accurate disability benefits in accordance with statutory requirements.
• Identify and investigate potential fraud or abuse in coordination with the Special Investigation Unit.
• Establish and maintain appropriate claim reserves, adjusting as needed based on evolving claim circumstances.
• Negotiate settlements within authority levels and collaborate with legal counsel on litigated claims.
• Ensure Medicare compliance, including coordination of Medicare Set-Aside Trusts when applicable.
• Maintain thorough documentation and data accuracy in all claim files and systems.
• Provide timely updates on high-exposure or high-profile claims to management.
• Collaborate cr
📌 Claims Representative II (Colombia)
🏢 MEM
📍 Colombia