Job Details

Associate Claims Representative

Are you an organized, relationship-driven professional with a passion for helping people navigate important moments in their recovery? MEM Insurance is looking for an Associate Claims Representative to join our dedicated Claims team. In this role, you willindependently manage a caseload of workers' compensation claimsinvestigating coverage and compensability, coordinating medical care, managing disability and return-to-work processes, and supporting fair, well-documented claim resolutions.

You'll work closely with medical providers, policyholders, attorneys, and internal partners to ensure injured workers receive quality care while also protecting the financial well-being of our policyholders. This is a professional-level role where you'll balance analytical decision-making with compassionate customer servicehelping people during some of their most challenging times.

Essential Duties and Responsibilities

Claims Investigation, Evaluation & Administration

• Conduct thorough investigations of workers' compensation claims, including coverage analysis, compensability decisions, and collection of statements and documentation.
• Identify coverage concerns, subcontractor issues, or other complexities and escalate when appropriate.
• Maintain well-organized claim files with clear documentation, action plans, and timely updates.
• Establish, monitor, and adjust reserves to ensure accuracy and alignment with corporate expectations.
• Manage claims from initial report through final disposition, prioritizing workload to meet quality and productivity standards.

Medical & Disability Management

• Oversee the medical aspects of claims, ensuring injured workers receive appropriate, cost-effective treatment.
• Collaborate with network providers, Nurse Case Management, Utilization Management, and specialists to guide care decisions.
• Review and process medical bills with accuracy and timeliness.
• Secure wage statements, calculate disability benefits correctly, and ensure payments follow statutory requirements.
• Manage Return-to-Work efforts, educating policyholders on light-duty options and helping employees resume safe, meaningful work.

Fraud Prevention, Subrogation & Loss Recovery

• Identify potential fraud indicators and collaborate with the Special Investigations Unit as needed.
• Investigate subrogation opportunities and document third-party liability to maximize recovery.
• Recognize when field visits or surveillance may be beneficial and coordinate those activities responsibly.

Claim Resolution, Negotiation & Legal Collaboration

• Obtain required disability ratings and evaluate settlement options within authority limits.
• Collaborate with internal and external counsel to execute legal strategy, review legal bills, and ensure litigation guidelines are followed.
• Address Medicare exposure appropriately, securing Medicare Set-Asides when required.
• Identify opportunities for structured settlements.

Reporting, Communication & Cross-Functional Partnership

• Communicate claim status to policyholders, producers, and internal stakeholders with professionalism and clarity.
• Provide claim updates on high-profile or high-dollar cases as requested.
• Partner with Underwriting, Premium Consultation, and Loss Prevention on risk concerns and claim trends.
• Support team members when colleagues are out of office.

Professional Development & Mentorship

• Engage in ongoing learning to stay current with workers' compensation laws, regulations, and industry practices.
• Assist in onboarding and supporting new Claims team members.

Qualifications

• Education: High school diploma or equivalent experience required; bachelor's degree preferred.
• Experience: 12 years of claims handling experience with exposure to workers' compensation preferred.
• Licenses: Valid driver's license required.
• Certifications: AIC or other insurance designations preferred.