Workers Compensation Claims Examiner II/III

Job Description

Job Description

Role Summary

The Claims Examiner II/III is a senior-level professional responsible for managing the full lifecycle of workers’ compensation indemnity claims, from inception through resolution, within established authority and guidelines. This role handles highly complex claims and plays a critical part in ensuring compliance with state regulations, timely investigations, accurate reserving, and effective claim resolution. The position requires strong analytical judgment, excellent communication skills, and consistent collaboration with clients, claimants, vendors, legal counsel, and internal teams.

This is an excellent opportunity for an experienced claims professional seeking autonomy, complexity, and impact in a hybrid work environment.

Duties and Responsibilities

• Manage a caseload of approximately 125–150 workers’ compensation claims, including highly complex and litigated files.

• Handle claims within Pennsylvania and New Jersey jurisdictions in compliance with applicable state laws and company guidelines.

• Initiate and conduct timely, thorough investigations to determine compensability.

• Administer benefits and manage claims in accordance with statutory requirements and organizational policies.

• Oversee medical treatment and medical billing, authorizing services as appropriate.

• Refer claims to outside defense counsel and direct legal strategy as needed.

• Communicate effectively with claimants, medical providers, vendors, clients, and internal stakeholders regarding claim status and issues.

• Establish and manage claim reserves within company guidelines, with higher authority limits than lower-level examiner roles.

• Negotiate, settle, and finalize claims, obtaining appropriate settlement authority when required.

• Maintain accurate and well-documented claim files, including diary systems for timely case review.

• Proactively communicate relevant information to clients to promote efficient claim resolution and identify injury trends or safety concerns.

• Collaborate with loss control staff when appropriate to address risk management opportunities.

• Conduct independent file reviews to ensure quality, compliance, and best practices.

• Adhere to all company policies, procedures, and performance standards.

• Perform other related duties as assigned.

Required Qualifications

• Bachelor’s degree in a related field (preferred).

• Minimum of three (3) years of workers’ compensation claims experience, or an equivalent combination of education and experience.

• Strong technical knowledge of workers’ compensation statutory regulations and medical terminology.

• Advanced analytical and problem-solving skills.

• Excellent written and verbal communication skills, with the ability to clearly explain technical concepts to claimants, clients, and colleagues.

• Proven ability to interact professionally with individuals at all levels of an organization.

• Ability to independently manage highly complex and high-exposure claims with minimal supervision.

• Proficiency in Microsoft Word and Excel (preferred).

Desired Qualifications

• Experience handling multi-state workers’ compensation claims.

• Prior experience managing litigation and working closely with defense counsel.

• Demonstrated success in settlement negotiation and reserve management.

Location and Work Type

• Work Type: REMOTE

• Office Presence: Regular, timely attendance in the office is required due to the collaborative and client-facing nature of the role