Claims Examiner

Main Function

Responsible for the administration of medical-only workers' compensation claims including but not limited to conducting a thorough investigation, managing medical care, and working towards final claims closure. 

Outline of Responsibilities

• Thoroughly investigate claims and make compensability decisions. Communicate orally and in writing file directions and decisions with clients, injured workers and provider offices. Determine subrogation recovery opportunities and handle through conclusion. Adjudicate medical bills. Estimate and establish reserves on all claims for probable final payout. Manage medical care to ensure reasonableness and appropriateness following established medical protocols. Review and document all claims correspondence to proactively manage the claims. Maintain a claim follow-up diary system. Facilitate in-person or telecon claim reviews as required. Review and document all claims correspondence to proactively manage the claims. Allocated Loss Adjustment Expenses in management of claims. Document claim activity in file notes including a solid current status & plan of action. Provide prompt and efficient service to clients on all client requests. Proper use of the Pharmacy Benefit Manager Program. Proper use of in-house Telephonic Nurse Case Managers. Properly close all claims once all claim issues are resolved.   Report appropriate claims to excess carrier. Other duties as defined.

Qualifications

Bachelor’s degree and/or prior experience working in a high volume process environment, processing claims, or previous workers’ compensation or equivalent experience, required. Ability to independently multi-task and prioritize in a fast-paced environment in the management of claims. Possess excellent oral and written communication skills, strong attention to detail, as well as the ability to work well with others and be a positive team player.  Critical thinking skills that can transfer to the ability to interpret workers’ compensation medical records and State Workers’ Compensation Acts.  Adaptability to meet ever-changing needs of clients as well as an intermediate knowledge of Microsoft Office. Occasional overnight travel.

We offer a competitive salary with an excellent benefits package. 

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other legally protected status.