Claims Examiner

Job Description

Job Description

Job Profile

Job Title: Claims Examiner

Location: Remote,

Hire Type: Contingent

Pay Range: $32/hr.

Work Model: Remote

Work Shift: Monday-Friday 8 am – 4:30 pm

Recruiter Contact: Sean Craft I View email address on ziprecruiter.com I View phone number on ziprecruiter.com

Nature & Scope:

Positional Overview

We are seeking an experienced Claims Examiner – Workers’ Compensation to manage complex and high-exposure workers’ compensation claims. This role is responsible for analyzing technically difficult claims, determining benefits due, managing litigated cases, and ensuring proper adjudication in alignment with service expectations, industry best practices, and client-specific requirements.

The Claims Examiner will also identify subrogation opportunities, negotiate settlements within designated authority, and ensure cost-effective claim resolution while maintaining compliance with statutory guidelines.

Role & Responsibility:

Tasks That Will Lead to Your Success

• Analyze and process complex or technically challenging workers’ compensation claims by conducting thorough investigations to determine claim exposure.
• Develop and execute strategic action plans to drive timely and appropriate claim resolution.
• Negotiate settlements within designated authority levels.
• Establish and maintain accurate and timely claim reserves; ensure reserve adequacy throughout the life of the claim.
• Calculate and approve benefit payments, adjustments, and settlements within authority guidelines.
• Prepare and submit required state filings within statutory deadlines.
• Manage the litigation process and coordinate with defense counsel to ensure cost-effective outcomes.
• Coordinate vendor referrals for additional investigation, medical management, or litigation support.
• Apply cost containment strategies, including use of strategic vendor partnerships.
• Manage claim recoveries including subrogation, Second Injury Fund recoveries, and Social Security and Medicare offsets.
• Report claims to excess carriers and respond promptly to requests for direction.
• Communicate claim activity and updates with claimants and clients, maintaining strong professional relationships.
• Ensure claim files are properly documented and coded accurately.
• Escalate cases to supervisors or management as appropriate.

Skills & Experience

Qualifications That Will Help You Thrive

• High School Diploma or GED required.
• Bachelor’s degree preferred.
• Professional certifications relevant to workers’ compensation claims handling preferred.
• Minimum five (5) years of workers’ compensation claims management experience or equivalent combination of education and experience required.
• Experience handling high-exposure and litigated claims strongly preferred.
• Subject matter expertise in workers’ compensation insurance principles and applicable laws.
• Knowledge of recoveries, offsets, deductions, disability duration, and cost containment practices.
• Familiarity with medical management and Social Security/Medicare procedures related to workers’ compensation.
• Strong analytical and interpretive skills.
• Excellent verbal and written communication skills, including presentation ability.
• Proficiency in Microsoft Office and claims management systems.
• Strong organizational, interpersonal, and negotiation skills.
• Ability to work effectively in a team environment.
• Demonstrated ability to meet or exceed service expectations.