Claims Examiner - Workers Compensation

• Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
• Negotiates settlement of claims within designated authority.
• Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
• Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level. Prepares necessary state fillings within statutory limits.
• Manages the litigation process; ensures timely and cost effective claims resolution. Coordinates vendor referrals for additional investigation and/or litigation management.
• Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
• Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
• Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
• Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
• Ensures claim files are properly documented and claims coding is correct.
• Refers cases as appropriate to supervisor and management.
• Performs other duties as assigned.
• Supports the organization's quality program(s). Travels as required.

• Education & Licensing Bachelor's degree from an accredited college or university preferred.
• Professional certification as applicable to line of business preferred.
• Experience Five (5) years of claims management experience or equivalent combination of education and experience required.

• Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business.
• Excellent oral and written communication, including presentation skills PC literate, including Microsoft Office products Analytical and interpretive skills Strong organizational skills Good interpersonal skills Excellent negotiation skills.
• Ability to work in a team environment Ability to meet or exceed Service Expectations.

Last updated on Oct 20, 2023