Claims Examiner

Description:

• To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation

• To ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.

• Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.

• Negotiates settlement of claims within designated authority.

• Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.

• Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level.

• Prepares necessary state fillings within statutory limits.

• Manages the litigation process; ensures timely and cost effective claims resolution.

• Coordinates vendor referrals for additional investigation and/or litigation management.

• Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.

• Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.

• Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.

• Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.

• Ensures claim files are properly documented and claims coding is correct.

• Refers cases as appropriate to supervisor and management.

• Supports the organization's quality program(s).

• Travels as required.

QUALIFICATIONs:

• Bachelor's degree from an accredited college or university preferred.

• Professional certification as applicable to line of business preferred.

• Five (5) years of claims management experience or equivalent combination of education and experience required.

• Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business.

• Excellent oral and written communication, including presentation skills

• PC literate, including Microsoft Office products

• Analytical and interpretive skills

• Strong organizational skills

• Good interpersonal skills

• Excellent negotiation skills

• Ability to work in a team environment

• Ability to meet or exceed Service Expectations

• Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

• Physical: Computer keyboarding, travel as required

• 4+ years of California WC experience

• Must have SIP Certification

California Fair Chance Act:

Synectics Inc. will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if Synectics Inc. is concerned about conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report. Find out more about the Fair Chance Act by visiting calcivilrights.ca.gov/fair-chance-act/.