Claims Examiner - Workers Compensation

Description :

• To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation;
• to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements;

and to identify subrogation of claims and negotiate settlements.

Essential Functions And Responsibilities

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.

Additional Functions And Responsibilities

• Performs other duties as assigned.
• Supports the organization's quality program(s).

Qualification

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

Skills & Knowledge

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

Requirements : Manager's notes :

Manager's notes :

Any specific skill / certification / license :

Self insured certificate, experience handling public entities and school districts is preferred but not required.

Years of experience : at least years handling Indem claims, new losses, complex issues and litigation

Education Level :

High School Graduate / GED