Claims Examiner

1 month ago

San Diego, United States Synectics Full time

Description:

  • 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.
  • 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.
  • Performs other duties as assigned.
  • Supports the organization's quality program(s).
Qualifications:
  • Bachelor's degree from an accredited college or university preferred.
  • Professional certification as applicable to line of business preferred.
  • Five (5) years of claims management experience or equivalent combination of education and experience required.
  • Min 3 years of experience with CA claims mandatory.
  • 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.
  • Excellent oral and written communication, including presentation skills
  • PC literate, including Microsoft Office products
  • Analytical and interpretive skills
  • Strong organizational skills
  • Good interpersonal skills
  • Excellent negotiation skills
  • Ability to work in a team environment
  • Ability to meet or exceed Service Expectations
  • CA SIP preferred not mandatory


California Fair Chance Act:

Synectics Inc. will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if Synectics Inc. is concerned about conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report. Find out more about the Fair Chance Act by visiting calcivilrights.ca.gov/fair-chance-act/.

Benefits:

Healthcare Insurance: Synectics offers eligible employees and their dependents healthcare coverage through BlueCross BlueShield of Illinois. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics. Premiums are subsidized by Synectics.

Dental Insurance: Synectics offers eligible employees and their dependents a dental plan through MetLife. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics.

Vision Insurance : Synectics offers eligible employees vision insurance through VSP. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics.401(k) Plan: The Synectics Inc. Investment Savings Retirement Plan. Synectics offers all employees who are 21 years of age or older the opportunity to invest in the 401(k) Plan on the first enrollment date that is at least 30 days after employment begins. Enrollment dates are each January 1st, April 1st, July 1st, and October 1st.

Technical Certification Bonus: Synectics is pleased to award its employees a bonus of up to $500 for an approved professional certification. In determining the bonus amount, Synectics will consider the cost of the test(s) for any certification relating to your current position, achieved during your employment with us. Only one Certification Bonus per calendar year may be awarded per employee. Only current, active employees will be eligible to receive this bonus. It will be awarded 90 days after the Synectics office has received documentation confirming the successful completion of the certification.

Synectics is an equal opportunity employer.

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