Senior Claims Examiner: Complex Claims & Litigation

Jobtailor; Sacramento (CA); On-site; USD 70,000 - 95,000; Full time

Job summary

Jobtailor in Sacramento, CA seeks an experienced Claims Examiner to manage a diverse caseload of indemnity claims, including highly complex and litigated matters. You will initiate investigations, determine compensability, oversee medical treatment and billing, and coordinate with counsel and vendors to resolve claims efficiently.

Ideal candidates have 5+ years of related experience, strong analytical and communication skills, and licenses as required by the jurisdiction.

Qualifications

• Minimum five (5) years related experience or equivalent combination of education and experience.
• Technical knowledge of statutory regulations and medical terminology.
• Analytical skills.
• Excellent written and verbal communication skills, including conveying technical details to claimants, clients, and staff.
• Ability to interact with persons at all levels in the business environment.
• Ability to independently and effectively manage very complex claims.
• Licenses as required by Jurisdiction.

Responsibilities

• Effectively manages a caseload of indemnity claim files, including very complex and litigated claims.
• Initiates and conducts investigations in a timely manner.
• Determines compensability of claims and administers benefits based on state law and best practices.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Refer cases to outside defense counsel and participate in litigated matters.
• Communicates with claimants, attorneys, providers, and vendors regarding claims issues.
• Maintains a diary system for case review and documents file to reflect status and plan of action.
• Communicates information promptly to the client to resolve claims efficiently.
• Conducts file reviews as scheduled by the client and management.
• Identifies and reviews claims for the Apportionment assignment.
• Identifies and investigates subrogation potential and pursues recovery.
• Identifies claim criteria for excess reporting and reimbursement.
• Assists with State Audit and reporting responses.
• Mentors less experienced Examiners.
• Other duties as assigned, including claims management of other jurisdictional workers’ comp claims.

Skills

Claims Investigation

Compensability Determination

Medical Billing Management

Reserve Computation

Subrogation Identification

File Review

Claims Settlement

Diary System Maintenance

Audit Assistance

Tools

Microsoft Word

Microsoft Excel

Job description

Jobtailor in Sacramento, CA seeks an experienced Claims Examiner to manage a diverse caseload of indemnity claims, including highly complex and litigated matters. You will initiate investigations, determine compensability, oversee medical treatment and billing, and coordinate with counsel and vendors to resolve claims efficiently.

Ideal candidates have 5+ years of related experience, strong analytical and communication skills, and licenses as required by the jurisdiction.