Claims Examiner - Workers Compensation

ObjectWin Technology; Ontario (CA); Remote; USD 65,000 - 85,000; Full time

Job summary

A leading company in the workers' compensation sector is seeking a Claims Examiner to manage complex claims and ensure accurate adjudication. The role involves negotiation, litigation management, and collaboration with vendors, along with a focus on maintaining client relationships and service expectations. The ideal candidate will have substantial experience in claims management and relevant certifications.

Qualifications

• Preferred bachelor's degree from an accredited college or university.
• Five years of claims management experience or equivalent.
• SIP certification is mandatory.

Responsibilities

• Analyzes and processes complex workers' compensation claims.
• Negotiates settlement of claims within designated authority.
• Manages the litigation process for claims resolution.

Skills

Analytical skills

Negotiation skills

Communication skills

Interpersonal skills

Organizational skills

Education

Bachelor's degree

Tools

Microsoft Office

Job description

Claims Examiner - Workers Compensation
Remote CA
3 Months – Contract

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

Manager's note:-
Work location: Remote within CA.
Experience - min 3 years of relevant CA WC experience
SIP is mandatory.
Public entity and County of Los Angeles Experience is a plus.
Shift timings: 8:00 – 4:30