Workers Compensation Claims Examiner (TEXAS Jurisdiction)

POSITION DETAILS



POSITION SUMMARY
COMPANY has an immediate need for a full-time Senior Claims Examiner to support our workers compensation department. This position is offered as a fully remote work from home opportunity and the schedule for this position is Monday-Friday at 37.5 hours a week. The Senior Claims Examiner will adjust workers' compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, setting reserves, and negotiating settlements.



PRIMARY RESPONSIBILITIES
Candidates should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:

• Process new claims in compliance with client's Service Agreement
• Establish contact with employer to review issues
• Respond to inquiries from the employer, employee, doctors, and attorneys
• Establish and maintain appropriate reserves
• Review legal correspondence and medical reports
• Evaluate and approve medical procedures and treatment
• Administer benefits and ensure appropriateness of all payments
• Investigate coverage, liability, and monetary value of claim
• Review medical and legal bills for appropriateness
• Discuss appropriateness of medical treatment with medical case manager
• Determine compensability
• Monitor and assist litigation
• Negotiate settlement of claim, liens, rehabilitation plans, etc.
• Prepare and present reports to clients
• Appropriately close claims
• Help resolve client billing and payment inquiries
• Investigate complaints from injured workers
• Document and code the claim files and claims system with all relevant information
• Maintain and update action plans within specified time frames
• Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks
• Contact with employers, employees, attorneys, doctors, vendors and other parties
• Provide customer service and support to clients and claimants
• Work collaboratively with attorneys to draft settlements and assist with litigation strategies
• Negotiate settlements
• Authorize and negotiate cost of medical treatment and supplies
• Internal communication with staff
• Prepare professional, well written correspondence and other communications

ESSENTIAL POSITION REQUIREMENTS
The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.

• High School Diploma or equivalent (GED) required for all positions
  • AA/AS or BA/BS preferred but not required
• The Texas 03 Workers' Compensation license is required
  • The 08 All Lines License is preferred
• 3+ years recent workers compensation claims handling experience required
• At least 5 years of workers compensation claims experience preferred
• Solid knowledge of workers compensation laws, policies, and procedures'
• Completion of IEA or equivalent courses
• Proficiency in determining case value and negotiating settlements
• Understanding of medical and legal terminology
• Mathematical calculating skills

• Well-developed verbal and written communication skills with strong attention to detail
• Excellent organizational skills and ability to multi-task
• Ability to type quickly, accurately and for prolonged periods
• Proficient in Microsoft Office Suite
  • Ability to learn additional computer programs
• Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution
• Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization
• Seeks to include innovative strategies and methods to provide a high level of commitment to service and results
• Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner
• Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor.
• COMPANYs' operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.
• Must be able to reliably commute to meetings and events as required by this position

This description portrays in general terms the type and levels of work performed and is not intended to be all-inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self-education, prior experience, or on-the-job training.


COMPANY is an Equal Opportunity/ Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability, or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.


COMPANY is dedicated to fair and equitable compensation for our employees that is both competitive and reflective of the market. The estimated rate of pay can vary depending on skills, knowledge, abilities, location, labor market trends, experience, education including applicable licenses & certifications, etc.