Workers Compensation Claims Examiner

Job Description

Job Description

Job Profile  

Job Title:  Claims Examiner

Location: Remote

Hire Type: Contingent

Pay Range: $67/hr.

Work Model:   Remote

Work Shift: Monday-Friday 8 am – 4 pm

Recruiter Contact:   Sean Craft I View email address on us.fitly.work I View phone number on us.fitly.work

 

Nature & Scope:

Positional Overview

We are seeking an experienced Workers Compensation Claims Examiner to manage and resolve complex workers’ compensation claims. This role is responsible for analyzing claim exposure, determining benefits due, handling litigated and high-exposure claims, negotiating settlements, and ensuring claims are adjudicated in accordance with client requirements, industry regulations, and best practices.

The ideal candidate will possess strong investigative, analytical, and negotiation skills, along with extensive experience handling workers’ compensation claims from inception through resolution.

Role & Responsibility:

Tasks That Will Lead  to Your Success

 

• Analyze and process complex workers’ compensation claims by conducting investigations and gathering information to determine claim exposure and compensability.
• Develop and execute strategic action plans to drive claims toward timely and appropriate resolution.
• Negotiate settlements within established authority limits.
• Calculate, establish, and maintain appropriate claim reserves throughout the life of the claim.
• Determine benefits due and authorize claim payments and adjustments in accordance with applicable regulations and authority levels.
• Prepare and submit required state filings within statutory deadlines.
• Manage litigated claims and coordinate with defense counsel, medical providers, investigators, and other vendors to ensure efficient claim resolution.
• Utilize cost-containment strategies and vendor partnerships to minimize claim costs while maintaining quality outcomes.
• Identify and pursue recovery opportunities, including subrogation, Second Injury Fund recoveries, and Social Security or Medicare offsets.
• Report claims to excess carriers and respond to requests for information and direction in a timely and professional manner.
• Maintain regular communication with claimants, clients, attorneys, medical providers, and internal stakeholders regarding claim activity and status.
• Ensure claim files are accurately documented and properly coded within the claims management system.
• Escalate complex issues and claims to management as appropriate.
• Support organizational quality initiatives and perform additional duties as assigned.

 

Skills & Experience

Qualifications That Will Help You Thrive

 

• High school diploma or GED required.
• Bachelor’s degree from an accredited college or university preferred.
• Professional certifications related to workers’ compensation claims handling preferred.
• Minimum of five (5) years of workers’ compensation claims management experience or an equivalent combination of education and experience.
• Experience handling complex, litigated, and high-exposure workers’ compensation claims preferred.
• Strong understanding of California workers’ compensation laws and regulations is highly desirable.
• In-depth knowledge of workers’ compensation insurance principles, laws, and claims management practices.
• Understanding of reserve management, claim recoveries, offsets, and deductions.
• Knowledge of medical management practices and Social Security/Medicare procedures.
• Strong investigative, analytical, and problem-solving skills.
• Excellent negotiation and settlement management abilities.
• Strong written and verbal communication skills, including presentation capabilities.
• Proficiency in Microsoft Office Suite and claims management systems.
• Strong organizational and time management skills with the ability to manage multiple priorities.
• Ability to work independently and collaboratively in a team environment.
• Commitment to delivering exceptional customer service and meeting performance expectations.