Claims Examiner - Workers Compensation

***Only qualified Workers' Compensation candidates located in California are eligible to be considered for this role***

Location Requirement:
•Candidates must be located in the state of California.

Required Education:
• High School Diploma or equivalent.

Preferred Education:
• Bachelor's Degree from an accredited college or university.

Required Certifications/License:
• CA adjuster certification.

Required Experience, Knowledge & Skills:
• Minimum three years of experience with CA claims is mandatory.
• Three years of CA workers' compensation claims 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

Claims Examiner 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 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 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 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.**