Selective Insurance Company of America

  • WC Claims Representative-Tier 1

    Location US-NC-Charlotte
    Experience (Years)
    Full-Time Regular
    FLSA Status
    Job ID
    Travel %
    Auto Reimbursement
  • Overview

    Responsibility includes effective and timely communication with employer, employee, and medical provider.
    Investigate lost-time claims to determine coverage and compensability based on jurisdictional guidelines. Obtain relevant information necessary for a thorough investigation. Freeze facts of claims and make timely decisions. Effective and consistent partnership with nurse management to return injured worker back to gainful employment when necessary. Manage administration of benefits and claim resolution. Provide compelling customer service. All job duties and responsibilities must be carried out in compliance with applicable legal and regulatory requirements.


    This position requires knowledge of NY, CT, MA, RI and NH Jurisdiction.


    1. Receives assigned lost-time claims for investigation to determine coverage and compensability on claims with a short disability period of 8 weeks or less (could occasionally exceed 8 weeks).
    2. Processes claims which include the following activities: Making contacts, setting reserves, establishing file in MCS, evaluating exposure and establishing initial and subsequent reserves on less severe claims with a general exposure of less than $25,000, and analyzing investigational data. Makes timely payments and follow through to resolution. May occasionally handle claims that exceed $25,000.
    3. Documents claim files and maintains control of work through documentation or diary system. 
    4. Handle non-litigated claims only.
    5. File state forms timely in accordance with statutory guidelines.
    6. Collaborate with nurses and vendors on medical and disability management.
    7. Prepare for and participate in claims review and settlement conferences.
    8. Ensures compliance with company, state and federal regulations.


    Knowledge of workers compensation statutes, coverage and case law.  Excellent written and verbal communication skills.  Working knowledge of medical treatment and terms as related to medical only workers compensation claims.  Critical thinking skills to assess compensability of WC claim as it relates to the facts and law.


    College degree preferred.

    1-3 years of claims experience preferred.


    Selective is an Equal Employment Opportunity employer. Selective maintains a drug-free workplace.


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