Description: Our client is currently seeking a Claims Examiner - Workers Compensation in California (Remote)
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.
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.
Requirements:
At least 3 or more years of experience
Must reside in CA - remote in CA
Agile work schedule (may consider remote)
SIP is not mandatory, but preferred
Experience on JURIS definitely preferred.
Contact: r.singh@judge.com
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