Claims Specialist

Salary: $74,100.00 - $104,800.00 Annually
Location : Wauwatosa, WI
Job Type: Full-Time
Remote Employment: Flexible/Hybrid
Job Number: 20253
Department: Claims
Division: Worker's Compensation
Opening Date: 02/05/2025
Closing Date: 2/21/2025 5:00 PM Central
FLSA: Exempt
Bargaining Unit: N/A
Department: Worker's Compensation

Summary of Job
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.
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!

View what employees say about working at CVMIC!

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.

* The salary range represents the 2025 range, not the hiring range.
Health and Dental Insurance:
CVMIC contributes the full premium cost of Health and Dental family or single coverage for full-time employees (effective on the first of the month following thirty (30) days of employment), subject to annual approval by the Board of Directors.

Holidays: 10 paid holidays / 2 Floating Holidays
Vacation:

• 7 Days per year (Less than one year)
• 12 Days per year (1-4 years of service)
• 15 Days per year (5-9 years of service)
• 20 Days per year (10-14 years of service)
• 22 Days per year (15-19 years of service)
• 25 Days per year (20+ years of service)

Education:
With the advance approval of the Chief Executive Officer (CEO), CVMIC will reimburse an employee for up to 75% of the cost of tuition, books and testing charges relating to approved educational, courses or certificate programs.

Retirement Benefits:

Employees are eligible to participate in the retirement plans after completing one year of service with CVMIC.

• Simplified Employee Pension Plan (SEP): Under this plan, CVMIC has historically contributed an amount of an employee's earnings. The CVMIC Board of Directors determines which entity administers these funds.
• Deferred Compensation: CVMIC currently makes available to its employees, on a voluntary basis, participation in a deferred compensation plan. Under this plan, each employee may, on a tax-deferred basis, contribute up to 15% (with a maximum annual contribution established by the IRS) of gross earnings. CVMIC provides no contributions to this plan.

Life Insurance:
CVMIC provides a basic term life insurance policy (subject to annual approval by the Board of Directors). The amount of term insurance provided depends upon the employee's position and salary at CVMIC

Disability Insurance:
CVMIC provides a basic disability insurance policy for all full-time employees, subject to annual approval by the Board of Directors.
Sick Leave: 1 day per month, with a maximum accrued carry-over of 120 days.
01

Please identify the answer which best describes your level of education.

• High school degree or equivalent.
• One year post high school education.
• Associate's degree.
• Three years post high school education.
• Bachelor's degree.
• Advanced degree (Master's, Law or Ph.D.).

02

Please indicate the number of years of claims handling experience you have.

• Under 3 years of experience.
• 3 - 5 years of experience.
• 5 - 7 years of experinece.
• 7 - 10 years of experience.
• Over 10 years of experience.

03

Do you have experience utilizing claims software?

• Yes
• No

04

If you answered 'yes' to the above question, please provide details of the claims software you have experience using. If you do not have this experience, please type N/A.)
05

Please identify your level of authority before supervisory approval is required.

• $10,000 or less
• $10,001 - $25,000
• $25,001 - $50,000
• Over $50,000

Required Question