NEW JOB OPENING
CLAIMS EXAMINER - WORKERS COMPENSATION
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.



Required Certifications/License:

• SIP is mandatory.



Required Experience:

• Five (5) years of claims management experience or an equivalent combination of education and experience is required.



Skills & Knowledge

• Subject matter expert on appropriate insurance principles and laws for line-of-business handling, recoveries offsets and deductions, claim and disability duration, and 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



Responsibilities:

• 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.

• Calculate and assign timely and appropriate reserves to claims; manage reserve adequacy throughout the life of the claim.

• Calculate and pay benefits due, approve and make timely claim payments and adjustments, and settle claims within the designated authority level.

• Prepare 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 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.

• Refer cases as appropriate to supervisor and management.



ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• 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.**