Claims Examiner

Job Description

Job Title: Claims Examiner

Location: New Haven, CT

Duration: 3 Months (CTH)

Job Description

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• 3+ years of Workers’ Compensation Claim Examiner or Commensurate Experience (Having experience in worker’s compensation is not a requirement, but a nice thing to have, as long as the skills they do have are transferable).
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DUTIES AND RESPONSIBILITIES:

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• Handles all aspects of workers’ compensation claims from set-up to case closure ensuring strong customer relations are maintained throughout the process.
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• Reviews claim and policy information to provide background for investigation.
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• Conducts 3-part ongoing investigations, obtaining facts and taking statements as necessary, with insured, claimant, and medical providers.
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• Evaluates the facts gathered through the investigation to determine compensability of the claim.
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• Informs insureds, claimants, and attorneys of claim denials when applicable.
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• Prepares reports on investigation, settlements, denials of claims and evaluations of involved parties, etc.
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• Timely administration of statutory medical and/or indemnity benefits throughout the life of the claim.
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• Sets reserves within authority limits for medical, indemnity and expenses and recommends reserve changes to Team
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• Leader throughout the life of the claim.
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• Reviews the claim status at regular intervals and makes recommendations to Team Leader to discuss problems and remedial actions to resolve them.
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• Prepares and submits to Team Leader unusual or possible undesirable exposures when encountered.
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• Works with attorneys to manage hearings and litigation
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• Controls and directs vendors, nurse case managers, telephonic cases managers and rehabilitation managers on medical management and return to work initiatives.
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• Comply with customer service requests including Special Claims Handling procedures, file status notes and claim reviews.
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• Files workers’ compensation forms and electronic data with states to ensure compliance with statutory regulations.
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• Refers appropriate claims to subrogation and secures necessary information to ensure that recovery opportunities are maximized.
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• Works with in-house Technical Assistants, Special Investigators, Nurse Consultants, Telephonic Case
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• Managers as well as Team Supervisors to exceed customer's expectations for exceptional claims handling service.
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TECHNICAL SKILLS & COMPETENCIES:

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• Claim Examiner position with prior experience in workers’ compensation as a claim examiner, or commensurate examiner experience in paralegal, short-term / long-term disability, auto personal injury protection / medical injury, general liability, medical billing or as a claim technical assistant for lost time claims.
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• Requires knowledge of workers’ compensation statutes, regulations, and compliance.
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• Ability to incorporate data analytics and modeling into daily activities to expedite fair and equitable resolution of claims and claim issues.
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• Exceptional customer service and focus.
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• Ability to openly collaborate with leadership and peers to accomplish goals.
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• Demonstrates a commitment to a career in claims.
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• Exceptional time management and multi-tasking capabilities with consistent follow-through to meet deadlines.
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• Use analytical skills to find mutually beneficial solutions to claim and customer issues.
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• Ability to prepare and make exceptional presentations to internal and external customers.
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• Conscientious about the quality and professionalism of work products and relationships with co-workers and clients.
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• Willing to take ownership and tackle obstacles to meet Client's quality standards for service, investigation, reserving, inventory management, teamwork, and diversity appreciation.
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• Superior verbal and written communication skills.
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EXPERIENCE, EDUCATION & REQUIREMENTS:

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• Experience working in a customer focused, fast-paced, fluid environment
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• Experience utilizing strong communication and telephonic skills
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• Prior experience requiring a high level of organization, follow-up, and accountability
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• Prior workers’ compensation claim handling experience is a plus but not required
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• Familiarity with claim handling (healthcare, short-term / long-term disability, auto personal injury protection / medical injury, medical billing, or general liability) is a plus but not required
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• Prior insurance, legal or corporate business experience is a plus but not required
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• AIC, RMA, or CPCU completed coursework or designation(s) is a plus but not required
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• Proficiency with Microsoft Office Products
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• Knowledge of medical terminology is a plus but not required
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• Knowledge of bill processing is a plus but not required
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• Claim Adjuster licenses in Connecticut, New Hampshire, Rhode Island and Vermont, are necessary; however, they are not required at the time of posting for the position.
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• If you do not already have one, you will be required to obtain an applicable resident or designated home state adjusters license and possibly additional state licensure.
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