NEW JOB OPENING
CLAIMS EXAMINER
IN Remote, USA!

***Only qualified workers' compensation candidates located in California may apply for this role***



Required Education:

• High School Graduate/GED.



Preferred Education

• A bachelor’s degree from an accredited college or university is preferred.



Preferred Certifications/License:

• California SIP is preferred.



Required Experience:

• Minimum three years of experience with CA claims is mandatory.

• Five years of claims management experience or an equivalent combination of education and experience is required.



Skills & Knowledge:

• Subject matter expert of appropriate insurance principles and laws for the 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 the 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



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.



Job Duties :

• 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 the settlement of claims within the 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 claims within the designated authority level.

• Prepares necessary state filings 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 the 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 for 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 the supervisor and management.



Additional Job Duties

• Performs other duties as assigned.

• Supports the organization’s quality program(s).

• Travels as required.

• **Only those lawfully authorized to work in the designated country associated with the position will be considered.**

• **Please note that all Position start dates and duration are estimates and may be reduced or lengthened based upon a client’s business needs and requirements.**