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Experienced Claims Analyst

2 months ago

New Haven, Connecticut, United States Sunrise Systems, Inc. Full time

Position Title: Senior Claims Examiner

Company: Sunrise Systems, Inc.

Job Type: Contractual Position

Work Arrangement: Hybrid Model

Key Responsibilities:

  • Manage all phases 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.
  • Compile 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 suggest reserve adjustments to the Team Leader.
  • Regularly review claim statuses and recommend actions to the Team Leader to address issues and implement solutions.
  • Prepare and report any unusual or potentially problematic exposures to the Team Leader.
  • Collaborate with legal representatives to manage hearings and litigation processes.
  • Oversee and direct vendors, nurse case managers, and rehabilitation managers in medical management and return-to-work strategies.
  • Fulfill customer service requests, including special 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 provide exceptional claims handling services.

Required Skills & Qualifications:

  • Prior experience as a Lost Time Claim Examiner or equivalent roles in workers' compensation, paralegal work, or related fields.
  • In-depth knowledge of workers' compensation laws, regulations, and compliance requirements.
  • Ability to utilize data analytics and modeling in daily operations to facilitate fair claim resolutions.
  • Strong customer service orientation and ability to collaborate effectively with colleagues and leadership.
  • Demonstrated commitment to a career in claims management.
  • Excellent time management and multitasking skills with a consistent ability to meet deadlines.
  • Proficient analytical skills to identify mutually beneficial solutions for claims and customer concerns.
  • Capability to prepare and deliver outstanding presentations to both internal and external stakeholders.
  • Dedication to maintaining high-quality work standards and professional relationships.
  • Willingness to take initiative and address challenges to uphold quality service standards.
  • Exceptional verbal and written communication abilities.

Experience & Education:

  • Experience in a fast-paced, customer-oriented environment.
  • Strong communication and telephone skills.
  • Proven organizational skills with a focus on follow-up and accountability.
  • Familiarity with claims handling in various domains is advantageous but not mandatory.
  • Prior experience in insurance, legal, or corporate sectors is beneficial.
  • Relevant coursework or certifications in claims management is a plus.
  • Proficiency in Microsoft Office Suite.
  • Understanding of medical terminology is a plus.
  • Claim Adjuster licenses in relevant states are necessary, with the expectation to obtain them if not already held.