Workers Compensation Claims Examiner II

POSITION SUMMARY: Under general supervision and within established Company policies, procedures, claim handling standards, and applicable state regulations, assists in the administration and processing of workers’ compensation indemnity claims from inception to conclusion.This position performs claims handling activities in accordance with established workflows, supervisory direction, and designated authority guidelines. The Claims Examiner II regularly communicates with claimants, clients, medical providers, vendors, legal counsel, and internal staff regarding claim status, documentation, treatment coordination, and benefit administration.The position is classified as hourly non-exempt and is eligible for overtime compensation in accordance with applicable federal and California wage and hour laws. Employees are expected to accurately record all hours worked and obtain approval for overtime work consistent with Company policy.DUTIES AND RESPONSIBILITIES:Manages a workers’ compensation caseload generally ranging from approximately 110–130 files, depending on claim complexity, staffing levels, and operational needs.Reviews new claim assignments and completes timely initial claim setup and investigation activities following Company procedures and supervisory guidance.Gathers and documents claim-related information from claimants, employers, medical providers, and other parties.Applies established Company guidelines and applicable state regulations in the administration of indemnity and medical benefits.Coordinates medical treatment and reviews medical billing for processing and authorization within assigned authority levels and Company procedures.Maintains timely and accurate claim file documentation reflecting current claim status and activities performed.Utilizes the Company diary system to monitor claim activity and follow-up tasks.Communicates professionally with claimants, employers, medical providers, attorneys, vendors, and clients regarding routine claim matters and claim status updates.Prepares reserve recommendations and submits reserve changes for review and approval in accordance with Company guidelines and assigned authority levels.Escalates complex issues, coverage concerns, litigation matters, settlement recommendations, or questions outside assigned authority to supervisory staff.Participates in file reviews, team meetings, training activities, and operational discussions as requested by management.Assists in identifying claim trends, return-to-work opportunities, or safety concerns for client communication.Adheres to Company policies, attendance expectations, confidentiality requirements, and documentation standards.Performs other related duties as assigned.Essential job function.EQUIPMENT OPERATED/USED: Computer, 10-key, fax machine, copier, printer, and other office equipment.SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attireQUALIFICATIONS REQUIRED:Education/Experience: High school diploma or GED required; Bachelor’s degree in a related field (preferred); three (3) or more years of related experience; or equivalent combination of education and experience.Knowledge, Skills, and Abilities:Technical knowledge of statutory regulations and medical terminology.Analytical skills.Excellent written and verbal communication skills, including conveying technical details to claimants, clients, and staff.Ability to interact with persons at all levels in the business environment.Ability to independently and effectively manage fairly complex claims.Proficient in Word and Excel (preferred).Other Qualifications:NoneMental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]MENTAL AND PHYSICAL REQUIREMENTS1. MENTAL EFFORTa. Reasoning development::Follow one- or two-step instructions; routine, repetitive task.Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.Follow written, verbal, or diagrammatic instructions; several concrete variables.X Solve practical problems; variety of variables with limited standardization; interpret instructions.Logical or scientific thinking to solve problems; several abstract and concrete variables.Wide range of intellectual and practical problems; comprehend most obscure concepts.b. Mathematical development:Simple additional and subtraction; copying figures, counting, and recording.Add, subtract, multiply, and divide whole numbers.X Arithmetic calculations involving fractions, decimals, and percentages.Arithmetic, algebraic, and geometric calculations.Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.c. Language development:Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.X Ability to compose original correspondence, follow technical manuals, and have increased contact with people.Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.2. PHYSICAL EFFORTa. Physical activity required to perform the job:Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.X Light work:a. Exerting up to 20 pounds of force occasionallyb. Exerting up to 10 pounds frequentlyc. Exerting a negligible amount of force constantly to move objects(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).Medium work:a. Exerting up to 50 pounds of force occasionallyb. Exerting up to 20 pounds of force frequentlyc. Exerting up to 10 pounds of force constantly to move objectsHeavy work:a. Exerting up to 100 pounds of force occasionallyb. Exerting up to 50 pounds of force frequentlyc. Exerting up to 20 pounds of force constantly to move objectsVery heavy work:a. Exerting in excess of 100 pounds of force occasionallyb. Exerting in excess of 50 pounds of force constantly to move objectsc. Exerting in excess of 20 pounds of force constantly to move objectsVisual requirements necessary to perform the job:Far vision: clarity of vision at 20 feet or moreX Near vision: clarity of vision at 20 inches or lessX Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feetDepth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually areColor vision: ability to identify and distinguish colorsField of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point2. PHYSICAL EFFORT (cont.)FREQUENCYc. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.X Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.X Kneeling: Bending legs at knee to come to a rest on knee or knees.X Crouching: Bending the body downward and forward by bending legs and spine.Crawling: Moving about on hands and knees or hands and feet.X Reaching: Extending hand(s) and arm(s) in any direction.X Standing: Particularly for sustained periods of time.X Walking: Moving about on foot to accomplish tasks, particularly for long distances.X Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.X Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.FootMotion: Using feet to push pedals.X Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.X Grasping: Applying pressure to an object with the fingers and palm.OccasionallyOccasionallyOccasionallyOccasionallyOccasionallyOccasionallyOccasionallyOccasionallyFrequentlyFrequentlyOccasionally2. PHYSICAL EFFORT (cont.)FREQUENCYX Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts.Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.X Repetitive Substantial movements (motions) of the wrists, hands,Motion: and/or fingers.FrequentlyFrequentlyFrequently3. WORKING CONDITIONSDisagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.WORKING CONDITIONENVIRONMENTALFACTORNATURE/REASONOF EXPOSUREFREQUENCYDirt/DustNoiseTemperature extremesDampnessVibrationsEquipment movement hazardChemicals/solventsElectrical shockSignificant work pace/pressureOdors/FumesOther (specify): #J-18808-Ljbffr Tristar-d43fac80