Claims Examiner

Role Overview

• Responsible for managing workers’ compensation claims as assigned by claims supervisor
• Investigates claims
• Determines the compensability of the claim and extent of liability
• Communicates directly with clients, employers, injured workers, physicians, and attorneys to bring claims to a timely conclusion
• Interviews, telephones, or corresponds with claimant and witnesses; consults police and hospital records
• Contacts physicians to obtain medical diagnoses and projected treatment plans
• Monitors medical progress of claimants and coordinates follow-up treatments; reports to employers including any restrictions that may be imposed on claimants’ return to work
• Documents all information from contacts with employers, claimants, physicians, and attorneys into the claims’ management system and ensures that documentation is current
• Calculates and sets reserves through a reserve worksheet including the nature and scope of claims; adjusts reserves to reflect ultimate known exposures
• Issues medical, indemnity, legal and expense payments
• Prepares reports for excess carriers and requests reimbursement when needed
• Sets reminders to follow-up on tasks through diaries on the system; reviews and completes diaries daily
• Maintains physical files for claim-related documents such as medical information, legal reports, and other correspondence
• Reviews claims’ submissions for thoroughness and accuracy
• Determines compensability of claims through information gathered and according to workers’ compensation statutes; makes recommendations as to compensability and coverage of claims
• Provides guidance and advice to clients on direction of claims after all information has been gathered and analyzed
• Ensures jurisdictional filings are complete and timely
• Obtains pre-certification approval for specific treatments as needed

Requirements

• Strong organization skills, attention to detail and the ability to multi-task and prioritize work are required
• Analytical thinking skills are needed to properly evaluate complex claims
• Good verbal and written communication skills, as well as interpersonal skills are required
• Experience with negotiations, knowledge of litigation process is preferred
• Ability to listen well and negotiate with constituents is needed
• Ability to speak a second language is an asset
• Basic computer skills or the ability to quickly learn new software are required
• A strong work ethic and time management skills is needed, to efficiently handle a caseload ranging from minor to complex claims
• Ability to establish and maintain good rapport with clients and claimants is needed
• Ability to calculate figures is required
• High school Diploma or equivalent is required
• 3+ years prior experience handling worker’s claims/ or an equivalent combination of training, education and experience
• Adjuster licensing required; (Multiple jurisdictions will be involved, will be required to have a license that will reciprocate to other states.) CA, AZ, LA, NV and UT licensing a plus

Benefits

• Comprehensive medical insurance, dental insurance, and vision insurance
• Life and disability insurance
• Fertility benefits
• Wellness resources
• Paid sick time
• Generous paid time off and holidays
• Employee Assistance Program (EAP)
• Complimentary Calm app subscription
• Immediate vesting in a 401(k) plan
• Health Savings Account (HSA) and Flexible Spending Account (FSA) options
• Commuter benefits
• Employee discount programs
• Paid maternity leave and paid paternity leave (including for adoptive parents)
• Legal plan options
• Pet insurance coverage