Claims Examiner

Acrisure • Culver City, CA

15h • Onsite

About The Position

Responsible for managing workers’ compensation claims as assigned by claims supervisor. Investigates claims. Determines the compensability of the claim and extent of liability. Communicates directly with clients, employers, injured workers, physicians, and attorneys to bring claims to a timely conclusion. Job Description Summary Essential Duties and Responsibilities include the following. Other duties may be assigned : Interviews, telephones, or corresponds with claimant and witnesses; consults police and hospital records. Contacts physicians to obtain medical diagnoses and projected treatment plans. Monitors medical progress of claimants and coordinates follow-up treatments; reports to employers including any restrictions that may be imposed on claimants’ return to work. Documents all information from contacts with employers, claimants, physicians, and attorneys into the claims’ management system and ensures that documentation is current. Calculates and sets reserves through a reserve worksheet including the nature and scope of claims; adjusts reserves to reflect ultimate known exposures. Issues medical, indemnity, legal and expense payments Prepares reports for excess carriers and requests reimbursement when needed. Sets reminders to follow-up on tasks through diaries on the system; reviews and completes diaries daily. Maintains physical files for claim-related documents such as medical information, legal reports, and other correspondence. Reviews claims’ submissions for thoroughness and accuracy. Determines compensability of claims through information gathered and according to workers’ compensation statutes; makes recommendations as to compensability and coverage of claims. Performs other duties as assigned. Additional Responsibilities: Provides guidance and advice to clients on direction of claims after all information has been gathered and analyzed. Ensures jurisdictional filings are complete and timely. Obtains pre-certification approval for specific treatments as needed.

Requirements

• High school Diploma or equivalent is required
• 3+ years prior experience handling worker’s claims/ or an equivalent combination of training, education and experience.'
• Adjuster licensing required; (Multiple jurisdictions will be involved, will be required to have a license that will reciprocate to other states.) CA, AZ, LA, NV and UT licensing a plus
• Strong organization skills, attention to detail and the ability to multi-task and prioritize work are required.
• Analytical thinking skills are needed to properly evaluate complex claims
• A strong attention to detail is necessary as claims adjusters must carefully review documents and policies
• Good verbal and written communication skills, as well as interpersonal skills are required, experience with negotiations, knowledge of litigation process is preferred.
• Ability to listen well and negotiate with constituents is needed.
• Basic computer skills or the ability to quickly learn new software are required
• A strong work ethic and time management skills is needed, to efficiently handle a caseload ranging from minor to complex claims
• Ability to establish and maintain good rapport with clients and claimants is needed.
• Ability to calculate figures is required

Nice To Haves

• Ability to speak a second language is an asset
• Candidates should be comfortable with an on-site presence to support collaboration, team leadership, and cross-functional partnership.

Responsibilities

• Interviews, telephones, or corresponds with claimant and witnesses; consults police and hospital records.
• Contacts physicians to obtain medical diagnoses and projected treatment plans.
• Monitors medical progress of claimants and coordinates follow-up treatments; reports to employers including any restrictions that may be imposed on claimants’ return to work.
• Documents all information from contacts with employers, claimants, physicians, and attorneys into the claims’ management system and ensures that documentation is current.
• Calculates and sets reserves through a reserve worksheet including the nature and scope of claims; adjusts reserves to reflect ultimate known exposures.
• Issues medical, indemnity, legal and expense payments
• Prepares reports for excess carriers and requests reimbursement when needed.
• Sets reminders to follow-up on tasks through diaries on the system; reviews and completes diaries daily.
• Maintains physical files for claim-related documents such as medical information, legal reports, and other correspondence.
• Reviews claims’ submissions for thoroughness and accuracy.
• Determines compensability of claims through information gathered and according to workers’ compensation statutes; makes recommendations as to compensability and coverage of claims.
• Provides guidance and advice to clients on direction of claims after all information has been gathered and analyzed.
• Ensures jurisdictional filings are complete and timely.
• Obtains pre-certification approval for specific treatments as needed.

Benefits

• Physical Wellness: Comprehensive medical insurance, dental insurance, and vision insurance; life and disability insurance; fertility benefits; wellness resources; and paid sick time.
• Mental Wellness: Generous paid time off and holidays; Employee Assistance Program (EAP); and a complimentary Calm app subscription.
• Financial Wellness: Immediate vesting in a 401(k) plan; Health Savings Account (HSA) and Flexible Spending Account (FSA) options; commuter benefits; and employee discount programs.
• Family Care: Paid maternity leave and paid paternity leave (including for adoptive parents); legal plan options; and pet insurance coverage.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED