Job Details

Claims Examiner III - Hybrid / Remote

This position will be Hybrid. BE SURE TO SIGN THE APPLICATION WHEN YOU APPLY

JOB SUMMARY: Investigates, evaluates, disposes and settles moderately complex to complex/high exposure claims. Includes the investigation, evaluation and determination of coverage, compensability and responsibility and the setting of proper reserves.

DUTIES AND RESPONSIBILITIES:

• Processes moderately complex to complex or high exposure claims consistent with clients' and corporate policies, procedures and "Best Practices" and in accordance with any statutory, regulatory and ethics requirements.
• Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim working within established level of authority.
• Interacts with injured workers, client contacts and attending Physician(s) to ensure awareness and understanding of the Workers' Compensation process, requirements and entitlements.
• Interacts with disability and leave examiners for coordination of non-occupational benefits.
• Prepares and issues notices in accordance with mandated requirements and regularly reviews and stays abreast of applicable laws, rules and regulations that may impact how claims are processed.
• Establishes and maintains proper reserving throughout the life of the claim.
• Identify subrogation potential and pursue the process for reimbursement.
• Complies with carrier excess reporting and threshold requirements.
• Coordinates medical treatment for injured workers and provides information to treating physician(s) regarding the employee's medical history, health issues and job requirements.
• Fully understands Medicare reporting requirements as they relate to a Workers' Compensation claim.
• Facilitates early RTW through temporary, transitional, alternate, or modified work.
• Manages all medical aspects of a claim file with a focus on RTW and end of treatment.
• Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc. up to assigned authority.
• Monitors status and quality of work performed.
• Serves as a liaison between medical providers, employees, legal professionals, clients and vendors.
• Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop strategy.
• Enters and maintains accurate information in the claims management computer system.
• Clearly communicates concise action plans and present plans for moving the claim to resolution.
• Meets with clients to discuss on-going claims or review open claim inventory.
• Effectively controls expenses on all Workers' Compensation claims.
• Mentors first level WC Examiners.
• All other duties as assigned.

Qualifications

This is a hybrid position....please sign the application at the end

Education: High School Diploma or GED required: Bachelor's degree in related field (strongly preferred) or equivalent combination of education and experience.

Experience: Three (3) to five (5) years of Workers' Compensation Claims administration experience required working with self-insured and/or insured claims.

Licenses/Certificate: SIP

Preferred Skills:

• Demonstrated experience working with complex, high exposure and litigated WC claims.
• Appropriately licensed and/or certified in all States in which claims are being handled. Multi-Jurisdiction experience is a (+).
• Bilingual Spanish is a (+)
• Able to work in a fast paced, high stress, changing environment.
• Strong analytical, critical thinking and problem-solving skills required.
• Effective verbal and written communication skills required.
• Excellent planning, organizing and negotiation skills required.
• Attention to detail.
• Negotiation and interpretive skills necessary.
• Demonstrated knowledge of established claims strategy and mitigation techniques.
• Establishes and maintains effective working relationships with those contacted in the course of work.
• Proficiency with computers and technology working knowledge of Microsoft Office application suite (MS Word, Excel, etc. and familiarity and experience using standard claims administration applications.
• Good interpersonal skills with an ability to work within a team environment.
• Able to effectively handle multiple priorities simultaneously.
• Works independently.

Here is some of the benefits you can enjoy in this role

• Medical, Dental, Vision, Life insurance & Disability
• 401 (k) plan
• Paid holidays.
• Paid time off.

Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]

MENTAL EFFORT

a. Reasoning development:

Follow one- or two-step instructions; routine, repetitive task.

Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

Solve practical problems; variety of variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve problems; several abstract and concrete variables.

Wide range of intellectual and practical problems; comprehend most obscure concepts.

b. Mathematical development:

Simple additional and subtraction; copying figures, counting, and recording.

Add, subtract, multiply, and divide whole numbers.

Arithmetic calculations involving fractions, decimals, and percentages.

Arithmetic, algebraic, and geometric calculations.

Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.

Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

c. Language development:

Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.

Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.

Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.

Ability to compose original correspondence, follow technical manuals, and have increased contact with people.

Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

2. PHYSICAL EFFORT

a. Physical activity required to perform the job:

Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Light work:

a. Exerting up to 20 pounds of force occasionally

b. Exerting up to 10 pounds frequently

c. Exerting a negligible amount of force constantly to move objects

(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

Medium work:

a. Exerting up to 50 pounds of force occasionally

b. Exerting up to 20 pounds of force frequently

c. Exerting up to 10 pounds of force constantly to move objects

Heavy work:

a. Exerting up to 100 pounds of force occasionally

b. Exerting up to 50 pounds of force frequently

c. Exerting up to 20 pounds of force constantly to move objects

Very heavy work:

a. Exerting in excess of 100 pounds of force occasionally

b. Exerting in excess of 50 pounds of force constantly to move objects

c. Exerting in excess of 20 pounds of force constantly to move objects

1. Visual requirements necessary to perform the job: