Pinnacol Assurance · 13 hours ago
Senior Claims Representative
Denver
Full-time
Onsite
Mid, Senior Level
$81K/yr - $86K/yr
3+ years expPinnacol Assurance is dedicated to providing caring workers’ compensation protection to Colorado employers and employees. The Senior Claims Representative will manage claims and related issues, ensuring expedient and cost-effective resolutions while providing quality customer service to all stakeholders.
BankingFinance
Responsibilities
Work with team members to strategically and proactively manage claims and claim-related issues to the most expedient, cost effective resolution; provide quality customer service to all stakeholders which includes proactive communication and follow through at all times
Identify claims that need complex management and work with team members to resolve concerns, escalate to the appropriate level or secure appropriate resources
Must demonstrate consistent follow through with all stakeholders to ensure efficient and effective resolution of each issue and claim
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
Be able to manage the relationships with your stakeholders in order to obtain timely and accurate information in order to complete this process
Effectively and proactively communicate your decisions and evaluate for customer understanding
Determine compensability as required by Company best practices, case law and the Colorado Workers’ Compensation Act
Proactively 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, comorbid 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
Coordinate and oversee all necessary resources on a timely basis for optimal claim management, action plan development and claim resolution, including other claims team members, Claims Lead, Claims Owners, Underwriters, Business Director, Legal resources, Return-to-Work Consultant, Safety Consultant, Medical Case Manager, Utilization Review, MedPay Liaison, Provider Relations Specialist and Claims Director
Proactively 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
Correspondence includes phone, email, fax, possible face to face meetings, and accurate claim documentation
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 well as filing all appropriate paperwork with the Colorado DOWC as required by Company best practices, case law and the Colorado Workers’ Compensation Act
Evaluate claims for settlement by determining most likely medical path and return to work possibilities
May include estimation of indemnity benefits including permanent impairment
Negotiate settlement with the help of in house or external legal counsel
Negotiate settlement directly with injured workers or their counsel
Facilitate completion of settlement documents and obtain approval from the DOWC as required by Company best practices
Provide authority for level 1 and 2 CRs to settle claims within senior CR authority
This includes examination of their settlement evaluation, coaching on opportunities where appropriate, and documentation of the authority
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 by reviewing medical records and determining the likely future treatment for the specific injury and circumstances
Must utilize knowledge of likely treatment and outcomes for a variety of injuries, as well as predict the cost of that treatment
Must actively monitor and update current reserves by re-evaluating changing circumstances on all open claims
Provide authority for level 2 CRs to reserve claims within senior CR authority
Review the proposed reserve, provide coaching where appropriate, and document the authority
Prepare for, attend and testify at settlement conferences and hearings
Evaluate medical bill referrals to determine relatedness to claim and appropriateness of the bill as required by Company documented best practices
Authorize payment of the bill or deny bill by obtaining appropriate supporting documentation
Communicate decisions to billers and parties to the claim
Read and analyze medical records in order to maintain a current and accurate understanding of a claims’ medical progress
Recognize when a treatment plan is outside of the authorized care
Communicate with internal and external resources to assist stakeholders with their management of the treatment plan
Process records as required by Company documented best practices
Serve as resource and mentor to level 1 and 2 claims representatives
Serve on projects and committees as requested
Maintain all Senior CR performance standards to ensure the best possible outcomes
Other duties as requested
Qualification
Required
3 or more years previous experience managing Colorado workers' compensation claims
Must have a working knowledge of all required computer systems
Must be meeting or exceeding all CR 2 metrics
Proficient in resolving indemnity claims in a timely and cost efficient manner
Benefits
You’ll get to choose from diverse benefit offerings for medical, dental and vision.
We enjoy a positive, collaborative work environment.
You’ll have the opportunity to earn a quarterly incentive, up to 12 percent of your annual base salary, when your team exceeds their goals and objectives.
Enjoy 20 paid days off your first full year plus 9 paid holidays.
Sign up for unique wellness programs, including on-site, company-paid fitness facilities and classes.
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.
Through our employee volunteer program, Pinnacol in Action, employees receive paid time off to volunteer with Colorado nonprofits.
Company
Pinnacol Assurance
Pinnacol Assurance is provide personalized attention that helps keep worksites safe.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Philip Kalin
President/CEO
Kathy Kranz
Vice President and Chief Financial Officer
Recent News
2025-10-02
2025-09-14
Company data provided by crunchbase