PRIMARY PURPOSE: To analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.
Job Duties:
- Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
- Develops and manages workers compensation claims’ action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
- Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
- Manages subrogation of claims and negotiates settlements.
- Communicates claim action with claimant and client.
- Ensures claim files are properly documented and claims coding is correct.
- May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
- Maintains professional client relationships.
- Performs other duties as assigned.
- Supports the organization’s quality program(s).
- Travels as required.
Qualifications:
- Self-insurance certification is a plus
- Bachelor’s degree from an accredited college or university preferred.
- Min 3+ years as indemnity examiner handling CA Claims WC experience required.
- Experience Four (4) years of claims management experience or equivalent combination of education and experience required.
- Working knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure 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 skill Good interpersonal skills
- Excellent negotiation skills
- Ability to work in a team environment
- Ability to meet or exceed
- 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
- Management retains the discretion to add or to change the duties of the position at any time.