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Claims Examiner

Location : Sacramento, CA
Job Type : Temp/Contract
Hours : Full Time
Travel : No
Relocation : No

Job Description :

PRIMARY PURPOSE:


To analyze mid-and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.



RESPONSIBILITIES



  • Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.

  • Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.

  • Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.

  • Manages subrogation of claims and negotiates settlements.

  • Communicates claim action with claimant and client.

  • Ensures claim files are properly documented and claims coding is correct.

  • May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.

  • Maintains professional client relationships.


 


Required Qualifications :


  • Four (4) years of claims management experience or equivalent combination of education and experience required.

  • Working knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure 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

  • Ability to work in a team environment

  • Ability to meet or exceed Service Expectations


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