Claims Examiner - Workers Compensation
Posted 1 week ago by 1753342493
Negotiable
Outside
Remote
USA
Summary: This remote position for a Claims Examiner in Workers Compensation requires a minimum of 6 years of experience in handling complex workers' compensation claims. The role involves analyzing claims, negotiating settlements, managing litigation processes, and ensuring compliance with statutory requirements. The candidate must possess strong communication and organizational skills, along with a deep understanding of insurance principles and laws relevant to the field.
Key Responsibilities:
- Analyze and process complex workers' compensation claims to determine exposure and manage claims through action plans.
- Negotiate settlements within designated authority and calculate timely reserves and benefits due.
- Manage the litigation process and coordinate vendor referrals for investigations and litigation management.
- Utilize cost containment techniques to reduce overall claims costs and manage claim recoveries.
- Communicate claim activity with claimants and clients while maintaining professional relationships.
- Ensure proper documentation and coding of claim files and refer cases to management as appropriate.
Key Skills:
- Subject matter expertise in insurance principles and laws relevant to workers' compensation.
- Excellent oral and written communication skills, including presentation abilities.
- Proficiency in Microsoft Office and strong analytical and interpretive skills.
- Strong organizational and interpersonal skills, with excellent negotiation capabilities.
- Ability to work effectively in a team environment and meet service expectations.
Salary (Rate): undetermined
City: undetermined
Country: USA
Working Arrangements: remote
IR35 Status: outside IR35
Seniority Level: undetermined
Industry: Other
Its a remote position.
Mandatory: Work comp claims handling experience is needed; loss time.
Minimum 6+years of relevant WC experience required.
PRIMARY PURPOSE:
To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate 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 clams within designated authority level. Prepares necessary state fillings 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 our 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.
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. Excellent oral and written communication, 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