Workers Compensation Claims Examiner
To analyze complex or technically difficult 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.
- Analyzes and manages complex or technically difficult 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.
- Assesses liability and resolves claims within evaluation.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 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.
- In-depth knowledge 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 procedure as applicable to line of business • Excellent oral and written communication, including presentation skills
- Four (4) years of claims management experience or equivalent combination of education and experience required.
- Education:Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.