Claims Examiner

KEMI•Lexington, KY

1d•Onsite

About The Position

The Claims Examiner will investigate claims to determine compensability in accordance with applicable statute, case law, and experience. This role administers medical benefits in strict accordance with state statutes and regulations, ensuring all treatment is work-related, medically necessary, and appropriate. The Claims Examiner will accurately calculate the injured workers’ average weekly wage and initiate indemnity benefits to ensure that injured workers are paid in a timely and accurate manner. This role also maintains appropriate claim reserves in strict accordance with company protocols, ensuring all financial documentation reflects the current and projected valuation of each case. The Claims Examiner drives claims toward resolution by developing and executing strategic action plans focused on return-to-work goals and proactive settlement, partnering with in-house counsel to utilize cost-effective annuities and Medicare Set-Asides, when appropriate. Comprehensive and timely file reviews are conducted to ensure all claims adhere to departmental guidelines, maintaining detailed documentation of strategy, reserves, and resolution paths. The Claims Examiner facilitates claimant understanding by educating injured workers on benefits and responding to all inquiries with speed and accuracy. This role drives account retention through proactive engagement with policyholders, ensuring high satisfaction levels by simplifying complex claims processes and delivering consistent, reliable outcomes. Transparent, timely communication with all stakeholders is maintained to ensure alignment and proactive claim resolution. The Claims Examiner actively manages the litigation process to ensure timely and cost-effective claim resolution and achieves employee SMART Goals. Other duties as requested.

Requirements

Strong organizational skills and attention to detail.
Ability to manage claims independently.
Proficient claims knowledge in indemnity claims.
Knowledge of medical terminology.
Strong analytical and sound decision-making skills.
Effective communication skills, both written and verbal.
Intermediate knowledge of Microsoft Word, Excel, and Outlook.
Ability to learn and efficiently operate software programs and business systems and adapt to changing technology.
Four years of progressive insurance experience.
Adjuster’s license and ODG certification required within one year of hire.
Workers’ Recovery Professional certification required within three years of hire.
Reliable attendance.
Adhere to all company policies.
Ability to interact professionally with coworkers, existing and potential customers.
Actively support the KEMI Mission, Vision, Values, and culture.

Nice To Haves

AIC designation preferred.
Bachelor’s Degree or licensed Registered Nurse preferred.

Responsibilities

Investigate claims to determine compensability in accordance with applicable statute, case law, and experience.
Administer medical benefits in strict accordance with state statutes and regulations, ensuring all treatment is work-related, medically necessary, and appropriate.
Accurately calculate the injured workers’ average weekly wage and initiate indemnity benefits to ensure that injured workers are paid in a timely and accurate manner.
Maintain appropriate claim reserves in strict accordance with company protocols, ensuring all financial documentation reflects the current and projected valuation of each case.
Drive claims toward resolution by developing and executing strategic action plans focused on return-to-work goals and proactive settlement, partnering with in-house counsel to utilize cost-effective annuities and Medicare Set-Asides, when appropriate.
Conduct comprehensive and timely file reviews to ensure all claims adhere to departmental guidelines, maintaining detailed documentation of strategy, reserves, and resolution paths.
Facilitate claimant understanding by educating injured workers on benefits and responding to all inquiries with speed and accuracy.
Drive account retention through proactive engagement with policyholders, ensuring high satisfaction levels by simplifying complex claims processes and delivering consistent, reliable outcomes.
Maintain transparent, timely communication with all stakeholders to ensure alignment and proactive claim resolution.
Actively manage the litigation process; ensure timely and cost-effective claim resolution.
Achieve employee SMART Goals.
Perform other duties as requested.