Claims Representative II

Pinnacol Assurance does just one thing, and does it better than anyone: provide caring workers’ compensation protection to Colorado employers and employees. And while we may be a little biased, we believe that our work shapes communities and changes lives.

We have big hearts and love big ideas. We’ve been around for more than  100 years, but don’t let that fool you. Pinnacol is committed to taking care of Colorado employers and workers in the most innovative ways. We celebrate continuous improvement, new ideas, compassion, teamwork, integrity and excellence.

With our number one priority to keep everyone safe, along with the heart of Pinnacol’s “culture of caring” to do what is right and not what is easy, we’re currently having our team members work from home. But we’re still making time for fun with virtual events like virtual painting classes, virtual yoga and Zumba classes, and virtual happy hours!

What you’ll do:

Work with team members to manage claims and claim-related issues to the most expedient, cost effective resolution; provide quality customer service to all stakeholders

What you can expect:

• Contact stakeholders as required by Company best practices on incoming claims to promptly investigate circumstances of accident and injury, investigate and determine compensability, and identify and address red flag issues, including late reporting, pre-existing medical issues, designated medical provider process and referral issues, medical treatment issues, legal issues, and potential subrogation and penalty issues
• Determine compensability as required by Company best practices, case law and the Colorado Workers’ Compensation Act
• Manage open claims as required by Company best practices, including expedient and cost effective medical case management, disability management, and litigation management, as well as identification, investigation, management and resolution of potential adverse claim development, including prior injuries, co-morbid and pre-existing medical conditions, migrating body parts, worsening medical conditions and delayed recovery, change of physician requests, multiple claims, multiple jobs, subrogation, penalties and offsets
• Facilitate all necessary resources on a timely basis for optimal claim management, action plan development and claim resolution, including other claims team members, Claims Lead, Underwriter, Business Director, Legal resources, Return-to-Work Consultant, Safety Consultant, Medical Case Manager, Utilization Review, MedPay Liaison, Provider Relations Specialist, Claims Specialist and Claims Manager.
• Communicate and correspond with stakeholders as needed to manage and resolve open claims, including but not limited to policyholders, injured workers, agents, medical providers, service vendors and resources, attorneys and regulatory agency representatives
• Facilitate early return to work for injured workers by working with policyholder, and Return-to-Work Consultant if needed
• Facilitate and coordinate benefit authorization and payment on compensable claims as required by Company best practices, case law and the Colorado Workers’ Compensation Act
• Evaluate and negotiate claims for settlement as required by Company best practices
• Inform policyholders and agents of claim status and significant development as required by Company best practices
• Review medical information received on claims to determine if authorization/payment is appropriate, or if referral is needed to other Company resources (utilization review, medical case manager, physician advisor, or others) as required by Company best practices and in compliance with DOWC Rules of Procedure
• Set and maintain current, accurate and adequate reserves on all open claims
• Prepare for, attend and testify at settlement conferences and hearings
• Process medical bill referrals as required by Company documented best practices
• Process medical records as required by Company documented best practices

What you need to be successful:

Bachelor’s Degree strongly preferred. Relevant work experience (similar kind of work at a similar level of work as described in the essential duties) may be substituted for the bachelor's degree. Completion of a degree is encouraged and supported. Knowledge of the workers’ compensation system required. Must successfully complete Anatomy and Medical Terminology assessment within 6 months of hire. Pursuit of continued claims education is encouraged and supported. Must demonstrate proficiencies of Claims Associate and/or have six months relevant workers’ compensation claims adjusting experience.

• Our benefits go beyond the basics. You’ll get to choose from diverse benefit offerings for medical, dental and vision.
• We care about each other. We enjoy a positive, collaborative work environment. We are hard workers and high performers.
• We love who you are. Pinnacol is on a journey to embody diversity, equity and inclusion. We’re committed to creating a culture that deeply values differences, where everyone feels like they belong.
• Take a day (or 20!) off. Enjoy 20 paid days off your first full year plus 9 paid holidays.
• Take care of yourself. Sign up for unique wellness programs, including on-site, company-paid fitness facilities and classes
• Get your learning on. We promote a learning culture to help you master your current job and cultivate the skills of the future through a variety of on-site, online, and off-site professional development opportunities.
• Give back and get paid. Through our employee volunteer program, Pinnacol in Action, employees receive paid time off to volunteer with Colorado nonprofits.
• Share in our success. You’ll have the opportunity to earn a quarterly incentive, up to 20 percent of your annual base salary, when your team exceeds their goals and objectives.

When we find the right person, we try to put our best foot forward with an offer that excites you. We consider what you’d like to be paid, the skills and experience you bring, what similar jobs pay in the Denver area and make sure there’s equal pay for equal work among those you’ll be working with. The compensation amount for this role is targeted at $62,000-$65,400. Final offer amounts are determined by multiple factors including your experience and expertise and may vary from the amounts listed above.

Want to love your work? Apply today!

Pinnacol is committed to working with and providing reasonable accommodations to applicants with disabilities. To request assistance with the application process, please email [email protected].