Senior Claims Examiner - Workers' Compensation (California)

icwgroup; Pleasanton (CA); On-site; USD 95,000 - 120,000; Full time

Job summary

ICW Group is seeking a Senior Claims Examiner to handle moderate to highly complex workers' compensation claims with a focus on service excellence for policyholders. The role requires navigating complex coverage concepts and coordinating with counsel to reach equitable resolutions.

The position emphasizes timely investigations, accurate reserving, and collaboration with internal teams to improve processes and outcomes.

Qualifications

• Bachelor's degree with 5+ years' claims handling experience
• Complex litigated claims experience is highly preferred
• Workers' Compensation certification preferred; state license may be required in some branches

Responsibilities

• Manages all aspects of a moderate to highly complex claims inventory.
• Communicates with policyholders, agents, attorneys, and witnesses to gather information and provide high-quality service.
• Investigates claims to determine exposure and makes strategic recommendations.
• Directs defense counsel through litigation per ICW Group guidelines and monitors costs.
• Prepares and presents claims status reports for internal and external stakeholders.
• Administers timely and appropriate benefits to injured workers and manages payments.
• Creates and adjusts reserves to align with policy and procedures.

Skills

Communication skills

Time management

Attention to detail

Flexibility

Learning new technology

Education

Bachelor's degree or equivalent

Workers' Compensation Certification (WCCA/WCCP) preferred

Tools

Claims software

Job description

Are you looking to make an impactful difference in your work, yourself, and your community? Why settle for just a job when you can land a career? At ICW Group, we are hiring team members who are ready to use their skills, curiosity, and drive to be part of our journey as we strive to transform the insurance carrier space. We're proud to be in business for over 50 years, and its change agents like yourself that will help us continue to deliver our mission to create the best insurance experience possible.

Headquartered in San Diego with regional offices located throughout the United States, ICW Group has been named for the twelfth consecutive year in a row and for the 20th time overall as a Top 50 performing P&C organization offering the stability of a large, profitable and growing company combined with a focus on all things people. It's our team members who make us an employer of choice and the vibrant company we are today. We strive to make both our internal and external communities better everyday! Learn more about why you want to be here!

PURPOSE OF THE JOB

The Senior Claims Examiner position handles moderate to complex claims with a focus on providing the highest level of service for policyholders and ICW Group to independently bring claims to an equitable conclusion within Company standards and best practice guidelines. The Senior Claims Examiner works with a sense of urgency, understands insurance coverage concepts, and navigates the legal system with the support of counsel to drive strategic outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Manages all aspects of a moderate to highly complex claims inventory.
• Effectively communicates with policyholders, agents, attorneys, and witnesses to gather information and provide the highest possible level of customer service.
• Promptly investigates claims to determine exposure, works with appropriate experts and makes strategic recommendations.
• Utilizes appropriate resolution tactics (e.g., mediation, negotiation, denial, litigation or offer) to proactively drive outstanding results.
• Operates within the requirements of related state and/or the governing entity rules and regulations as well as internal claims handling policies and procedures.
• Directs defense counsel throughout the litigation process in line with ICW litigation guidelines while monitoring legal fees and costs.

All Claims Examiners:

• Consistently provides exceptional customer service.
• Effectively collaborates with team members from various departments for project and process discussions.
• Makes recommendations for streamlining processes and adopting the industry's best practices.
• Ensures accuracy of data in claims system for compliance with applicable regulatory reporting.
• Provides knowledge transfer across the organization.
• Continuously seeks to improve technical skills by attending job related training and tracking current case law.
• Acts as a mentor and provides training for less experienced team members.
• Serves as a technical resource and mentors less experienced Team Members

Workers' Compensation Claims (Specific Responsibilities):

• Prepares and presents claims status reports for internal and external stakeholders.
• Administers timely and appropriate benefits to injured workers; manages and approves payment of benefits within designated authority level. Works within applicable state rules, regulations as well as ICW Group's internal claims handling policies and procedures.
• Creates and adjusts reserves in a timely manner to ensure reserving activities are consistent with company policies.
• Resolves claims fairly and equitably, acting in the best interest of the insured while providing timely benefits to injured workers as required by law.
• Provides technical guidance and collaborates with leadership on complex claim resolution strategies and specialty handling initiative
• Handles specialized claim inventories involving complex medical exposure, litigation, fatality, PTD, life pension, or long-term resolution strategies.
• Identifies and drives resolution opportunities on complex or long-duration claims through proactive settlement, reserving, and medical management strategies.

SUPERVISORY RESPONSIBILITIES

This position has no supervisory responsibility

EDUCATION AND EXPERIENCE

Bachelor's degree (or equivalent combination of education and experience) required along with a minimum of 5+ years' related claims handling experience required; complex litigated claims experience is highly preferred.

CERTIFICATES, LICENSES, REGISTRATIONS

Workers' Compensation: Certification that meets the minimum standards of training, experience, and skill required. WCCA and WCCP preferred. State Workers Compensation License is required in some branches.

KNOWLEDGE AND SKILLS

Good understanding of laws and jurisdictional restraints to manage claims

Excellent verbal communication skills, time management, attention to detail and organizational skills

Must be adept at learning new technology

Flexibility to adapt to changes