Claims Examiner - Workers Compensation

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Job description

Minimum 3 years of relevant CA WC claims experience is mandatory

California WC Claims handling experience

Must have OSIP certificate

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.

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.

Additional Functions and Responsibilities

Performs other duties as assigned.

Supports the organization s quality program(s).

Travels as required.

Qualification

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

Work Environment

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description.

They are not intended to constitute a comprehensive list of functions, duties, or local variances.

Management retains the discretion to add or to change the duties of the position at any time.

• Only those lawfully authorized to work in the designated country associated with the position will be considered.

• Please note that all Position start dates and duration are estimates and may be reduced or lengthened based upon a client's business needs and requirements.

Benefits:

For information and details on employment benefits offered with this position, please visit here . Should you have any questions/concerns, please contact our HR Department via our secure website .

California Pay Equity:

For information and details on pay equity laws in California, please visit the State of California Department of Industrial Relations' website here .

Rose International is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender (expression or identity), national origin, arrest and conviction records, disability, veteran status or any other characteristic protected by law. Positions located in San Francisco and Los Angeles, California will be administered in accordance with their respective Fair Chance Ordinances.

If you need assistance in completing this application, or during any phase of the application, interview, hiring, or employment process, whether due to a disability or otherwise, please contact our HR Department .

Rose International has an official agreement (ID ), effective June 30, 2008, with the U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services, Employment Verification Program (E-Verify). (Posting required by OCGA 13/10-91.).

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