Claims Manager

1 week ago

San Diego, California, United States Cynet Systems Full time
Claims Manager

Cynet Systems is seeking a highly skilled Claims Manager to join our team. As a key member of our organization, you will be responsible for analyzing and processing complex workers' compensation claims. Your expertise will be essential in negotiating settlements, ensuring timely and cost-effective resolution, and maintaining professional relationships with claimants and clients.

Key Responsibilities:
  • Claim Analysis and Resolution: Investigate and gather information to determine exposure on claims, and develop action plans to achieve timely resolution.
  • Negotiation and Settlement: Negotiate settlements within designated authority levels, ensuring fair and reasonable outcomes for all parties involved.
  • Reserve Management: Calculate and assign reserves to claims, ensuring adequacy throughout the life of the claim.
  • Benefits and Payments: Calculate and pay benefits due, approve and make timely claim payments and adjustments, and settle claims within designated authority levels.
  • State Filings: Prepare necessary state filings within statutory limits, ensuring compliance with regulatory requirements.
  • Litigation Management: Manage the litigation process, ensuring timely and cost-effective claims resolution.
  • Vendor Referrals: Coordinate vendor referrals for additional investigation and/or litigation management, as needed.
  • Cost Containment: Implement cost containment techniques, including strategic vendor partnerships, to reduce overall cost of claims for our clients.
  • Claim Recoveries: Manage claim recoveries, including subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.
  • Communication: Communicate claim activity and processing with claimants and clients, maintaining professional relationships.
  • Documentation: Ensure claim files are properly documented and claims coding is accurate.
  • Supervision: Refer cases to supervisor and management as necessary, ensuring seamless claim resolution.
Requirements:
  • Education: Bachelor's degree from an accredited college or university (preferred).
  • Certification: Professional certification applicable to line of business (preferred).
Experience:
  • Claims Management Experience: Five years of claims management experience or equivalent combination of education and experience required.
Skills and Knowledge:
  • Subject Matter Expertise: Subject matter expert in insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles, and medical management practices.
  • Knowledge of Social Security and Medicare: Knowledge of Social Security and Medicare application procedures applicable to line-of-business.
  • Communication and Interpersonal Skills: Excellent oral and written communication, including presentation skills, and strong interpersonal skills.
  • Analytical and Interpretive Skills: Analytical and interpretive skills, with the ability to analyze complex data and make informed decisions.
  • Organizational and Time Management Skills: Strong organizational and time management skills, with the ability to prioritize tasks and meet deadlines.
  • Teamwork and Collaboration: Ability to work in a team environment, with a focus on collaboration and open communication.
  • Service Expectations: Ability to meet or exceed Service Expectations, ensuring exceptional customer service and satisfaction.

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