Workers Compensation Claims Examiner

4 weeks ago

Pasadena, California, United States Mary Kraft HR Full time
Job Description

Mary Kraft HR is seeking an experienced Workers Compensation Claims Examiner to analyze complex or technically challenging workers' compensation claims and determine benefits due. The role involves providing guidance to other examiners, managing high-exposure claims involving litigation and rehabilitation, ensuring ongoing adjudication of claims within service standards, industry best practices, and specific client requirements.

Key Responsibilities
  • Analyze and process complex or technically difficult workers' compensation claims, including gathering information to assess claim exposure.
  • Develop and execute action plans for managing claims to achieve timely and appropriate resolution.
  • Approve and negotiate the settlement of claims within designated authority.
  • Calculate and assign appropriate reserves to claims, managing reserve adequacy throughout the claim's lifecycle.
  • Calculate and approve benefit payments, making timely adjustments and settlements.
  • Prepare necessary state filings within statutory limits.
  • Manage the litigation process, ensuring timely and cost-effective claims resolution.
  • Coordinate vendor referrals for additional investigations or litigation management.
  • Utilize cost-containment strategies, including strategic vendor partnerships, to reduce overall claim costs.
  • Manage claim recoveries, such as subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.
  • Report claims to excess carriers and respond to their inquiries in a professional and timely manner.
  • Maintain communication with claimants and clients, ensuring a professional relationship and adherence to service standards.
  • Ensure proper documentation of claim files and accurate claims coding.
  • Refer complex cases to management in line with client service instructions.
Requirements
  • High School Graduate/GED required; Bachelor's degree preferred.
  • Professional certification as applicable to workers' compensation claims preferred.
  • Five (5) years of claims management experience or equivalent combination of education and experience required.
  • Expertise in workers' compensation principles, laws, and claims handling.
  • Proficiency in claims analysis, negotiation, and resolution processes.
  • Strong communication skills, both written and verbal, including presentation skills.
  • Proficient with Microsoft Office and general PC usage.
  • Analytical and interpretive skills.
  • Strong organizational skills and attention to detail.
  • Good interpersonal skills and the ability to work well within a team.
  • Ability to consistently meet or exceed service expectations.

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