Senior Workers Compensation Claims Examiner

Job Description

Job Description

Pay Range: $45.00hr - $50.00hr

Job Overview:

The candidate will analyze complex or technically difficult workers' compensation claims to determine benefits due. This role involves managing high exposure claims involving litigation and rehabilitation to ensure adjudication within industry best practices and specific service requirements.

Primary Purpose:

The primary purpose of this role is to analyze complex or technically difficult workers' compensation claims to determine benefits due. The candidate will work with high exposure claims involving litigation and rehabilitation, ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements, while identifying subrogation of claims and negotiating settlements.

Essential Functions and Responsibilities:

• Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
• Negotiates settlement of claims within designated authority.
• Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
• Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
• Prepares necessary state filings within statutory limits.
• Manages the litigation process; ensures timely and cost effective claims resolution.
• Coordinates vendor referrals for additional investigation and/or litigation management.
• Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for the organization's clients.
• Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.
• Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
• Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
• Ensures claim files are properly documented and claims coding is correct.
• Refers cases as appropriate to supervisor and management.

Additional Functions and Responsibilities:

• Performs other duties as assigned.
• Supports the organization's quality programs.
• Travels as required.

Education & Licensing:

• Bachelor's degree from an accredited college or university preferred.
• Professional certification as applicable to line of business preferred.

Experience:

• Five (5) years of claims management experience or equivalent combination of education and experience required.

Skills & Knowledge:

• Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices, and Social Security and Medicare application procedures as applicable to line-of-business.
• Strong verbal and written communication skills, including presentation skills.
• PC literate, including Microsoft Office products.
• Analytical and interpretive skills.
• Strong organizational skills.
• Good interpersonal skills.
• Excellent negotiation skills.
• Ability to work in a team environment.
• Ability to meet or exceed Service Expectations.

Benefits:

Our Benefits Include:

• Medical, Dental, and Vision Insurance
• 401(k) Retirement Plan
• Health Savings Account (HSA)
• Disability Insurance (Short-Term and Long-Term)
• Life and AD&D Insurance
• Paid Sick Leave (where required by applicable state or local law)
• Supplemental Insurance Plans
• Identity Theft Protection
• Pet Insurance
• Employee Wellness Programs
• Employee Assistance Program (EAP)
• Career Growth and Professional Development Opportunities

Disclaimer : Benefits eligibility, accrual rates, and usage limits may vary based on employment status, length of service, and work location. Paid Sick Leave is provided in strict accordance with applicable state and municipal mandates. Cynet Systems Inc. reserves the right to modify, amend, or terminate any benefit plans at any time in accordance with applicable laws.

About Cynet Systems

Founded in 2010 and headquartered in the Washington, DC metro area, Cynet Systems Inc. is a leading technology staffing and workforce solutions company serving Fortune 500 companies, government agencies, and enterprise organizations across the United States and Canada. We deliver agile, scalable talent solutions across IT, engineering, life sciences, clinical, and professional staffing, powered by a high-performing recruitment engine operating across North America and Asia.

As a nationally and locally certified Minority Business Enterprise (MBE), Cynet Systems is committed to helping organizations build high-performing teams while empowering professionals to grow rewarding careers. Our organization is certified to ISO 9001, ISO 14001, ISO 27001, and SOC 2 Type II standards, reflecting our commitment to quality, security, operational excellence, and customer success.