Claims Examiner - Workers Compensation

Synectics Inc.; United States; On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Healthcare Insurance

Dental Insurance

Vision Insurance

401(k) Plan

Job summary

Synectics Inc. is seeking a skilled Workers’ Compensation Claims Examiner to analyze and manage complex CA claims, including litigation, subrogation, and cost containment.

You will negotiate settlements and calculate reserves while ensuring compliance with state laws and client requirements. The role requires a Bachelor's degree, SIP Certification, 5+ years of California WC experience, and strong negotiation, communication, and analytics skills.

Qualifications

• Bachelor's degree from an accredited college or university preferred.
• SIP Certification and California WC expertise highly regarded.
• 5+ years of claims management experience in California workers' compensation.
• Strong negotiation, analytical and communication skills.

Responsibilities

• Analyze complex workers' compensation claims and determine benefits and settlements.
• Investigate, gather information, and manage claims to timely resolution.
• Negotiate settlements within designated authority and manage reserves.
• Calculate and pay benefits, and document claim files accurately.
• Prepare state filings within statutory limits and coordinate litigation when needed.
• Coordinate vendor referrals for investigation or litigation management.
• Support cost containment and subrogation efforts for clients.
• Report claims to excess carriers and maintain client communications.
• Travel as required.

Education

Bachelor's degree

SIP Certification

Tools

Microsoft Office

Job description

Job Description

• 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.
• 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.
• Supports the organization's quality program(s).
• Travels as required.

Qualification

• Bachelor's degree from an accredited college or university preferred.
• Professional certification as applicable to line of business preferred.
• 5 years of claims management experience or equivalent combination of education and experience required.
• 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
• Workers Compensation Claims Examiner (3+ years of California WC experience)
• Must have SIP Certification
• Organized, able to handle avg of 5-8 new MO files, voice to voice calls for initial investigation
• Shift: m-f 8-4/4:30 ( Lunch 30 min/hour)

California Fair Chance Act

Synectics Inc. will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if Synectics Inc. is concerned about conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report. Find out more about the Fair Chance Act by visiting calcivilrights.ca.gov/fair-chance-act/

Benefits

• Healthcare Insurance: Synectics offers eligible employees and their dependents healthcare coverage through BlueCross BlueShield of Illinois. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics. Premiums are subsidized by Synectics.
• Dental Insurance: Synectics offers eligible employees and their dependents a dental plan through MetLife. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics.
• Vision Insurance: Synectics offers eligible employees vision insurance through VSP. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics.
• 401(k) Plan: The Synectics Inc. Investment Savings Retirement Plan. Synectics offers all employees who are 21 years of age or older the opportunity to invest in the 401(k) Plan on the first of the month following at least 1 calendar year after employment begins.

Synectics is an equal opportunity employer.