Workers Compensation Claims Examiner

4 weeks ago

San Diego, California, United States Mary Kraft HR Full time
Job Title: Workers Compensation Claims Examiner

Job Summary:

Mary Kraft HR is seeking an experienced Workers Compensation Claims Examiner to analyze complex or technically difficult workers' compensation claims. The role involves managing high-exposure claims, including those with litigation and rehabilitation, ensuring adherence to industry best practices, service expectations, and specific client requirements.

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.


About Mary Kraft HR:

Mary Kraft HR is a leading provider of workers' compensation claims management services. We are committed to delivering exceptional results and building long-term relationships with our clients.

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