Senior Claims Examiner - NorCal Remote or Hybrid

Athens Administrators, Inc.; San Francisco (CA); Hybrid; USD 85,000 - 120,000; Full time

Job summary

Athens Administrators is seeking a Senior Claims Examiner to support California workers’ compensation claims. This full-time role can be performed remotely within California or in a hybrid arrangement, with some in-office days from Concord or Orange offices as required by the supervisor.

Responsibilities include handling claims from inception to settlement, establishing reserves, directing medical treatment, and negotiating settlements.

Qualifications

• High School Diploma or equivalent (GED) required for all positions.
• AA/AS or BA/BS preferred but not required.
• Administrators Certificate from Self-Insurance Plans required within one year of employment.
• Current Experienced Indemnity Claims Adjuster designation, as defined by CA regulations.

Responsibilities

• Establish contact with employer to review issues.
• Respond to inquiries from employer, employee, doctors, and attorneys.
• Establish and maintain appropriate reserves.
• Review legal correspondence and medical reports.
• Evaluate and approve medical procedures and treatment.
• Administer benefits and ensure payment accuracy.
• Investigate coverage, liability, and value of claims.
• Review medical/legal bills for appropriateness.
• Discuss treatment with medical case manager.
• Monitor and assist litigation as needed.
• Negotiate settlements and liens.
• Prepare and present client reports.
• Close claims appropriately.
• Assist with training and mentoring staff.
• Communicate with employers, employees, attorneys, and vendors.

Skills

Workers' compensation knowledge

Claims handling

Negotiation skills

Communication skills

Regulatory compliance

Education

High School Diploma or equivalent

AA/AS or BA/BS preferred

Administrators Certificate (within 1 year)

Experienced Indemnity Claims Adjuster designation

Tools

Microsoft Office Suite

Job description

The best place to work for the highest performing people in the industry.

We’re always looking for exceptional professionals to join our team. Take a look at the positions currently available and consider if one might be right for you. If you do not see a position for your skillset currently, see below for a link to complete a general application, which will be received and saved by the Recruitment Team.

Position:Senior Claims Examiner - NorCal Remote or Hybrid

Location: Northern California, CA

Job Id:1656

# of Openings:1

ATHENS POSITION DETAILS

ATHENS ADMINISTRATORS

Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a “Best Place to Work.” Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family-owned company in Workers' Compensation, Property & Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today!

POSITION SUMMARY

Athens Administrators has an immediate need for a full-time Senior Claims Examiner to support our workers compensation offices and can be located anywhere in the state of California, however, employees who live less than 26 miles from the Concord, CA or Orange, CA offices are required to work once a week in the office on a day determined by their supervisor between Tuesday – Thursday. The remaining days can be worked remotely if technical requirements are met, and the employee resides in California. Athens offices are open for business Monday-Friday from 7:30 a.m. to 5:30 p.m. local time. The schedule for this position is Monday-Friday at 37.5 hours a week with the option of a flex schedule.

The Senior Claims Examiner will adjust workers’ compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, setting reserves, and negotiating settlements. The Senior Claims Examiner will adjust workers’ compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, setting reserves, and negotiating settlements.

PRIMARY RESPONSIBILITIES

Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:

• Establish contact with employer to review issues
• Respond to inquiries from the employer, employee, doctors, and attorneys
• Establish and maintain appropriate reserves
• Review legal correspondence and medical reports
• Evaluate and approve medical procedures and treatment
• Administer benefits and ensure appropriateness of all payments
• Investigate coverage, liability, and monetary value of claim
• Review medical and legal bills for appropriateness
• Discuss appropriateness of medical treatment with medical case manager
• Monitor and assist litigation
• Negotiate settlement of claim, liens, rehabilitation plans, etc.
• Prepare and present reports to clients
• Appropriately close claims
• Help resolve client billing and payment inquiries
• Investigate complaints from injured workers
• Document and code the claim files and claims system with all relevant information
• Maintain and update action plans within specified time frames
• Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks
• Contact with employers, employees, attorneys, doctors, vendors, and other parties
• Provide customer service and support to clients and claimants
• Work collaboratively with attorneys to draft settlements and assist with litigation strategies
• Negotiate settlements
• Authorize and negotiate cost of medical treatment and supplies
• Internal communication with staff
• Prepare professional, well written correspondence and other communications

ESSENTIAL POSITION REQUIREMENTS

The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.

• High School Diploma or equivalent (GED) required for all positions
  • AA/AS or BA/BS preferred but not required
• Administrators Certificate from Self-Insurance Plans will be required within one year of employment if not already obtained
• Must possess a current Experienced Indemnity Claims Adjuster Designation, provided by an insurer, as defined in California Code of Regulations, Title 10, Chapter 5, Subchapter 3, Section 2592.01(f)
• 3+ years recent workers compensation claims handling experience required
• At least 5 years of workers compensation claims experience preferred
• Solid knowledge of workers compensation laws, policies, and procedures’
• Completion of IEA or equivalent courses
• Proficiency in determining case value and negotiating settlements
• Understanding of medical and legal terminology
• Mathematical calculating skills
• Well-developed verbal and written communication skills with strong attention to detail
• Excellent organizational skills and ability to multi-task
• Ability to type quickly, accurately and for prolonged periods
• Proficient in Microsoft Office Suite
  • Ability to learn additional computer programs
• Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution
• Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization
• Seeks to include innovative strategies and methods to provide a high level of commitment to service and results
• Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner
• Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor.
• Athens’ operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.
• Must be able to reliably commute to meetings and events as required by this position

Athens Administrators is an Equal Opportunity/ Affiliation Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability, or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.

Athens Administrators is dedicated to fair and equitable compensation for our employees that is both competitive and reflective of the market. The estimated rate of pay can vary depending on skills, knowledge, abilities, location, labor market trends, experience, education including applicable licenses & certifications, etc. Our ranges may be modified at any time. In addition, eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments. We offer a variety of benefit plans including Medical, Vision, Dental, Life and AD&D, Long Term Care, Critical Care, Accidental, Hospital Indemnity, HSA & FSA options, 401k (and Roth), Company-Paid STD & LTD and more! Further information about our comprehensive benefits package may be found on our website at https://www.athensadmin.com/careers/why-work-here