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Workers Compensation Claims Examiner
2 months ago
Candidate selected to full this position must live within the state of Georgia. The employee's telecommuting work site location will contain a designated and approved workspace at the employee's home address.
General Definition of Work
Manages and resolves lost time and complex medical only claims on behalf of the Association's insurance programs to ensure prompt determination of compensability, payment of entitled benefits, litigation management and effective claim resolution, and related work as apparent or assigned. Work is performed under the supervision of the Claims Supervisor.
Position Responsibilities
- Initiates initial investigation for newly assigned insurance claims; confirms coverage of claim, contacts member, member representative, non-represented claimants, claimant's attorney and/or injured employees to obtain/provide information.
- Initiates compensability and/or liability determination through completion of statements, recorded statements, on-site investigations.
- Sets initial reserves for claims; performs proper and timely reserve evaluations and adjustments; reviews and approves bills for processing; reviews medical/rehabilitation notes; reviews and signs off daily check sheet; prepares and submits reports to excess carriers when loss is greater than one-half retention level.
- Establishes and maintains proper claim diary requirements of existing caseloads with documentation of action plans; ensures action plans are adhered to in a timely manner.
- Receives and responds to inquiries and requests for information from members, injured employees, vendors, case managers, legal representatives and medical providers.
- Completes Electronic Data Interchange (EDI) transmissions, state board filings and completes Centers for Medicare Services (CMS) requirements.
- Utilizes cost control measures regarding claims management when applicable including One Call Medical, Align, Telephonic Case Manager (TCM), Field Case Manager (FCM) and Surveillance; works at eliminating the payment of fines and penalties due to late and/or form filings.
- Occasional overnight travel required – less than 20 days per year – i.e. travel to mediations, hearings, depositions, account/member visits, and seminars.
- Education and Experience
- Bachelor's degree with coursework in business administration, insurance, or related field and
- Moderate (1 – 3 years) of related experience in workers' compensation claim administration, or
- Equivalent combination of education and experience.
Knowledge, Skills and Abilities
- Thorough knowledge of business English, spelling and arithmetic, standard office practices, procedures, equipment and administrative support techniques;
- Thorough knowledge of the workers' compensation system requirements and medical only claim administration;
- General knowledge of the laws, legal codes, court procedures, precedents, government regulations and agency rules regulating the workers compensation insurance industries; ability to make arithmetical calculations; ability to operate a variety of standard office equipment including personal computer and associated software;
- Ability to communicate ideas effectively in both oral and written formats; ability to type accurately at a reasonable rate of speed; ability to follow oral and written instructions; ability to read and understand detailed and complicated policies, procedures and materials that contain specialized words and phrases;
- Ability to establish and maintain effective working relationships with associates, claimants, attorneys, Nurse Case Managers, physicians, local government officials, customers and the general public.
Special Requirements
- Employee is required to have and maintain a high-speed, broadband internet connection at their work site that is sufficient to enable fast, consistent service to the membership. A minimum download speed of 25 Mbps is required. To ensure a consistent speed at this level, a 40MB internet connection is recommended. You may check your download speed at
- Possession of or ability to acquire a Georgia Independent Adjusters License issued through the State of Georgia Insurance Department within one year of employment.
- Valid driver's license in the State of Georgia.
