Claims Examiner – Workers Comp

Role Overview

• 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
• To identify subrogation of claims and negotiate settlements
• 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 claims within 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 overall cost of claims for 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 client; maintains professional client relationships
• Ensures claim files are properly documented and claims coding is correct
• Refers cases as appropriate to supervisor and management.

Requirements

• Bachelor's degree from an accredited college or university preferred
• Professional certification as applicable to line of business preferred
• Jurisdiction licensing needed: NH, VT, MA, CT, RI, DC, DE, WV, VA
• 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.

Benefits

• medical
• dental
• vision
• 401k and matching
• PTO
• disability and life insurance
• employee assistance
• flexible spending or health savings account
• other additional voluntary benefits