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Experienced Claims Specialist
2 months ago
Job Title: Senior Claims Analyst
Company: Sunrise Systems, Inc.
Position Type: Contractual Engagement
Work Model: Hybrid Schedule
Key Responsibilities:
- Manage all facets of workers' compensation lost time claims from initiation to resolution, ensuring excellent client relations are upheld throughout.
- Analyze claim and policy details to provide a foundation for thorough investigations.
- Conduct comprehensive investigations, gathering facts and obtaining statements from insured parties, claimants, and healthcare providers.
- Assess the information collected to determine the validity of claims.
- Communicate claim denials to insured parties, claimants, and legal representatives when necessary.
- Generate detailed reports on investigations, settlements, claim denials, and evaluations of involved parties.
- Administer statutory medical and indemnity benefits promptly throughout the claim lifecycle.
- Set reserves within authorized limits for medical, indemnity, and expenses, and recommend adjustments to the Team Leader as needed.
- Regularly review claim statuses and propose solutions to the Team Leader for any issues encountered.
- Prepare and present to the Team Leader any unusual or potentially problematic exposures.
- Collaborate with legal representatives to manage hearings and litigation processes.
- Oversee and guide vendors, nurse case managers, and rehabilitation managers in medical management and return-to-work strategies.
- Fulfill customer service requests, including specialized claims handling procedures and claim reviews.
- Ensure compliance with statutory regulations by filing necessary workers' compensation forms and electronic data with state authorities.
- Refer suitable claims for subrogation and gather essential information to maximize recovery opportunities.
- Work alongside in-house Technical Assistants, Special Investigators, and Team Supervisors to deliver exceptional claims handling services.
Required Skills & Qualifications:
- Prior experience in a lost time claims examiner role or equivalent experience in related fields such as paralegal work, disability claims, or general liability.
- Strong understanding of workers' compensation laws, regulations, and compliance requirements.
- Ability to utilize data analytics in daily operations to facilitate fair claim resolutions.
- Exceptional customer service orientation and interpersonal skills.
- Proven ability to collaborate effectively with team members and leadership.
- Demonstrated commitment to a career in claims management.
- Excellent time management and multitasking abilities, with a focus on meeting deadlines.
- Analytical skills to develop mutually beneficial solutions for claims and customer issues.
- Ability to prepare and deliver outstanding presentations to both internal and external stakeholders.
- Commitment to maintaining high standards of quality and professionalism in work and relationships.
- Willingness to take initiative and address challenges to meet organizational standards for service and teamwork.
- Strong verbal and written communication skills.
Experience & Education:
- Experience in a customer-centric, dynamic work environment.
- Strong communication and telephonic skills.
- Demonstrated organizational skills with a focus on follow-up and accountability.
- Familiarity with claims handling in various sectors is advantageous but not mandatory.
- Prior experience in insurance, legal, or corporate environments is beneficial.
- Completion of relevant coursework or certifications in claims management is a plus.
- Proficiency in Microsoft Office Suite.
- Knowledge of medical terminology and bill processing is beneficial but not required.
- Claim Adjuster licenses in relevant states are necessary; however, they can be obtained post-hire.
