Claims Examiner - Workers Compensation

Job Description

Job Description

Duties:
Minimum 3years of relevant CA WC claims experience is mandatory
California WC Claims handling experience
Must have OSIP certificate

Remote but within California

Primary Purpose:
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.

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.
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 clams within designated authority level.
Prepares 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 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 of 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.

Qualification:
Education & Licensing Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.

Experience:
Five (5) years of claims management experience or equivalent combination of education and experience required.