Claims Examiner - Workers Compensation

PRIMARY PURPOSE: To analyze complex or technically difficult 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.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

1. Analyzes and manages complex or technically difficult 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.
2. Assesses liability and resolves claims within evaluation.
3. Negotiates settlement of claims within designated authority.
4. Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
5. Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level.
6. Prepares necessary state fillings within statutory limits.
7. Manages the litigation process; ensures timely and cost effective claims resolution.
8. Coordinates vendor referrals for additional investigation and/or litigation management.
9. Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
10. Manages claim recoveries, including be not limited to subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
11. Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
12. Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
13. Ensures claim files are properly documented and claims coding is correct.
14. Refers cases as appropriate to supervisor and management.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

1. Performs other duties as assigned.
2. Supports the organization's quality program(s).
3. Travels as required.

QUALIFICATION

Education & LicensingBaccalaureate degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. Licenses as required.

ExperienceFour (4) years of claims management experience or successful completion of Claims Representative training required. BS/BA degree may substitute for two (2) years of required experience.

Skills & Knowledge

WORK ENVIRONMENTWhen applicable and appropriate, consideration will be given to reasonable accommodations. 

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

Auditory/Visual: Hearing, vision and talking

NOTE: Credit security clearance, confirmed via a background credit check, is required for this position.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.