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Role Description

Are you a seasoned claims professional with a passion for navigating complex cases? MEM Insurance is seeking a Senior Claims Representative to join our Claims team. In this pivotal role, you’ll manage high-exposure workers’ compensation claims, lead investigations into coverage and fraud, and collaborate across departments to drive strategic outcomes. You’ll be a key decision-maker, a mentor to junior adjusters, and a champion of process improvement—all while ensuring exceptional service and regulatory compliance.

• Manage highly complex claims involving significant financial exposure, legal intricacies, and extended life cycles.
• Conduct advanced investigations into coverage and compensability, including nuanced statutory interpretations.
• Oversee medical case management for catastrophic injuries and lifetime care needs.
• Review and authorize large or complex medical bills, negotiating adjustments to control costs.
• Develop comprehensive RTW strategies in collaboration with policyholders, legal counsel, and vocational consultants.
• Ensure precision in benefit calculations for high-exposure claims, addressing tax and compliance risks.
• Strategically deploy investigative efforts aligned with broader claims strategy.
• Lead investigations into complex fraud cases and collaborate with the Special Investigations Unit.
• Conduct subrogation analysis and negotiate with third-party insurers or attorneys for maximum recovery.
• Partner with legal teams to negotiate complex settlements and manage litigation processes.
• Oversee Medicare compliance initiatives, including Medicare Set-Asides and CMS engagement.
• Identify opportunities for structured settlements and lead negotiations.
• Produce strategic reports on high-profile claims to guide management decisions.
• Maintain system data integrity and prepare claims for Corporate Plan of Action meetings.
• Lead cross-departmental efforts to improve claims handling and risk management.
• Resolve escalated customer service issues and support high-value accounts.
• Participate in workflow improvement initiatives and committees.
• Mentor and coach junior and intermediate adjusters.
• Review escalated claims and provide actionable feedback.
• Support workforce development and succession planning.

Qualifications

• Bachelor’s degree in business or related field preferred, or equivalent industry experience.
• 7–10 years of claims handling experience, with high exposure to Workers’ Compensation.
• Associate in Claims (AIC), AIM, or CPCU designation preferred or ability to obtain.
• Texas All-Lines license preferred.
• Valid driver’s license required.

Benefits

• Medical, Dental, and Vision plans including fertility benefits, fully paid preventative care, and adult orthodontia.
• Employer-Paid Life and Disability Benefits: Life Insurance (3x base salary), AD&D, Short and Long-term Disability.
• Employer-paid incentives for employees and spouses through Wellness and Recognition Program.
• Flexible Spending Account and Dependent Care options.
• Health Savings Account with generous employer contribution.
• Generous PTO, 11 Holidays + 4 Early Releases, 16 Hours Volunteer Time Off, 20 Days Paid Parental Leave, Marriage, Bereavement, and Jury Duty leave.
• Employee Assistance Programs.
• 401k Retirement Plan with employer match and profit sharing.
• Adoption Assistance and Tuition Assistance.