A Claims Representative accepts and reviews applications for insurance and provides information to insurance agents. Assists insurance customers, answers questions and processes requests to change or cancel policies. May assist with insurance claims that are disputed, review claims and policy coverage and help to negotiate agreements between customers and an insurance company.
This position provides clerical and customer service support for claims processing while ensuring compliance with deadlines and regulations set by the Texas Department of Insurance, Division of Workers' Compensation. It includes coordinating incoming and outgoing communications, handling claim documentation, assisting adjusters with administrative tasks, and maintaining accurate records.
Qualifications:
Required Responsibilities:
Process faxes, Workers' Compensation emails, and Member portal documents to the appropriate claims. Completes activities in the claims management system assigned by adjusters, including phone calls, emails, correspondence, travel requests, medical reimbursements, and medical records requests. This may include gathering and emailing a large number of documents to medical providers and attorneys. Verifies and processes new claims, which may require direct communication with Members, providers, and claimants. Maintains office operations, including monitoring office and kitchen supply inventory and participating in training or cross-training as needed. Answers and returns phone calls, providing accurate information and assistance to providers, claimants, and Members. Prepares and processes outgoing and incoming mail, including faxes, emails, and returned mail. Researches and resolves unprocessed documents and medical bills, which may involve contacting claimants, Members, and providers to establish claims or return materials within required timeframes. Documents and enters claim-related data into the claim management system as provided by claimants, Members, attorneys, and providers. Performs tasks related to Electronic Data Interchange (EDI), including managing desktop queues, initiating manual EDI triggers, making corrections through the Verisk System, and collaborating with teams and vendors. Resolves tasks in the Mitchell Claim system and provider queues for medical bills, requiring detailed research, compliance tracking, and coordination with internal departments and providers for W9-related issues. Monitors and maintains the Explanation of Benefits portal, assisting providers with claim bill status inquiries. • The above responsibilities are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required by the position. All employees may have other duties assigned at any time. Job Requirements Education, Work Experience, Certifications•
Required:
High School diploma or equivalent
Years of Experience:
1
Area of Experience:
Workers Compensation, Administrative Work Equivalent combinations of education and experience will be accepted
Preferred:
None Essential Competencies and Skills•
Required:
Proficiency in MS Excel Proficiency in MS Word Proficiency in MS PowerPoint Proficiency in MS Outlook Proficiency in
MS Teams Preferred:
Proficiency in Adobe Acrobat Pro Proficiency in MS SharePoint Experience with Guidewire •To perform this job successfully, an individual must be able to perform each primary responsibility satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the primary responsibilities.
Supplemental Information:
Work Leadership Requirements:
This position is not a people manager. This position does not have indirect reports.
Travel Requirements:
None Physical Requirements:
Be able to withstand typical office work that includes periods of sitting, standing, typing, etc., indoors while potentially performing job tasks in close proximity to other people. In addition to typical office work, must be able to exert up to 10 pounds of force occasionally to move objects. Requires close visual acuity to perform an activity such as preparing and analyzing data and figures, viewing a computer screen, visual inspection, assembly of parts, or extensive reading. Ability to have a flexible work schedule to meet business needs and be at work on-site during specified or core hours. Must be able to operate standard computer hardware.
