Claims Examiner - Workers Compensation - Remote / Telecommute

Job Title: Claims Examiner - Workers Compensation - Remote / Telecommute

Job Location: Ontario, CA

Job Type: Contract

Pay Range: $50.00hr - $55.00hr

Job Overview:

The primary purpose of this role is to analyze complex or technically difficult workers compensation claims to determine benefits due. The candidate will 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, while identifying subrogation of claims and negotiating settlements.

Responsibilities:

The candidate analyzes and processes complex or technically difficult workers compensation claims by investigating and gathering information to determine the exposure on the claim. The successful candidate manages claims through well-developed action plans to an appropriate and timely resolution.

The candidate s responsibilities include supporting the organization s quality programs and performing other duties as assigned. Travel may be required.

• 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 the organization.
• 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.
• Strong verbal and written communication skills, 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.

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• Medical, Dental, and Vision Insurance
• 401(k) Retirement Plan
• Health Savings Account (HSA)
• Disability Insurance (Short-Term and Long-Term)
• Life and AD&D Insurance
• Paid Sick Leave (where required by applicable state or local law)
• Supplemental Insurance Plans
• Identity Theft Protection
• Pet Insurance
• Employee Wellness Programs
• Employee Assistance Program (EAP)
• Career Growth and Professional Development Opportunities