Workers Compensation Claims Examiner

1 month ago

San Diego, California, United States Mary Kraft HR Full time
Job Description

Mary Kraft HR is seeking an experienced Workers Compensation Claims Examiner to analyze complex claims and ensure adherence to industry best practices. The role involves managing high-exposure claims, including those with litigation and rehabilitation, and identifying subrogation opportunities.

Key Responsibilities
  • Analyze and process complex workers' compensation claims by investigating and gathering information to determine the exposure on the claim.
  • Manage claims through well-developed action plans, ensuring timely and appropriate resolutions.
  • Negotiate settlement of claims within designated authority limits.
  • Calculate and assign timely and appropriate reserves to claims; manage reserve adequacy throughout the life of the claim.
  • Approve and process claim payments, adjustments, and benefits, ensuring accuracy and timeliness.
  • Prepare necessary state filings within statutory limits.
  • Oversee the litigation process to ensure timely and cost-effective resolution of claims.
  • Coordinate vendor referrals for additional investigation or litigation management.
  • Implement cost-containment strategies, including partnerships with vendors, to reduce overall claim costs.
  • Manage claim recoveries, including subrogation, Second Injury Fund recoveries, and Social Security and Medicare offsets.
  • Report claims to excess carriers and respond to their inquiries in a timely and professional manner.
  • Maintain communication with claimants and clients, fostering professional relationships.
  • Ensure claims files are properly documented, with accurate coding.
  • Refer complex cases to supervisors or management as needed.
Requirements
  • Bachelor's degree from an accredited college or university preferred.
  • Professional certifications relevant to workers' compensation claims are preferred.
  • Five (5) years of claims management experience or an equivalent combination of education and experience required.
  • Minimum of 3 years of California workers' compensation claims handling experience is mandatory.
  • Self-Insurance Plan (SIP) certification is preferred but not mandatory.
  • Expertise in insurance principles and laws, claim and disability duration, and medical management practices.
  • Strong knowledge of Social Security, Medicare application procedures, and recovery processes.
  • Excellent communication skills, both oral and written, including presentation abilities.
  • Proficiency in Microsoft Office and general PC literacy.
  • Strong analytical, interpretive, and problem-solving skills.
  • Strong organizational skills and the ability to manage multiple priorities effectively.
  • Excellent negotiation skills.
  • Ability to work collaboratively in a team environment and meet or exceed service expectations.

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