This site uses cookies. To find out more, see our Cookies Policy

Claim Representative III in Sacramento, CA at AF Group

Date Posted: 11/28/2018

Job Snapshot

Job Description


Must have experience handling WC Claims in CA

Claim Representative III:

This is the advanced level of the claim handler career path. Investigates claims and exercises significant discretion in the determination of compensability of claims. May handle large, more complex customers requiring high touch, labor intensive claim service. Considers many factors in the determination claim reserves. Negotiates and settles claims within given authority. Mentors lower level claim handlers. Coordinates special projects and provides guidance to others.


Claim Representative I, II, III:

  • Verifies workers' compensation coverage of employers and injured employees.
  • Determines compensability under workers' compensation by thorough investigation of the claim.
  • Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
  • Facilitates return to work for the injured employee.
  • Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
  • Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
  • Manages medical bills for non-indemnity and indemnity claims directly associated with the claimed injury. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
  • Concludes and closes files following resolution of claims to meet internal performance standards while complying with state legislation to avoid penalties and manage expenses.
  • Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
  • Works closely with manager on complex files or files above settlement/reserve authority.
  • Manages outside vendors to ensure cost containment efforts.
  • Establishes and maintains effective working relationships with all internal and external customers.
  • Stays abreast of changes in workers' compensation statutes, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.



Claim Representative II, III:

  • Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
  • Exercises independent judgment to settle cases prior to mediation or litigation.
  • Actively participates in agent/client relationship management.
  • Assists in mentoring team members.

Claim Representative III:

  • Mentors team members.
  • Conducts audits of claim files.
  • Acts as a back up for team leader.
  • Coordinates special projects.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.


  1. Claims Examiner Jobs
  2. Claims Manager Jobs