Major Claims Examiner

ICW Group • Sacramento, CA

27d • Hybrid

About The Position

The Major Claims Examiner is responsible for managing complex, high-value workers’ compensation claims and ensuring timely, fair resolution in compliance with policy provisions while reducing financial exposure and supporting injured workers’ recovery. This position manages assigned major loss claims independently while adhering to company standards and state regulations.

Requirements

• Bachelor's degree in Business Administration, Management, Economics, Accounting, or related field (or equivalent combination of work experience and education).
• Minimum 10+ years’ workers’ compensation claims experience with specific experience managing and resolving major claims losses.
• Required to receive certification that meets the minimum standards of training, experience and skill.
• Maintain state Workers’ Compensation License, as required.
• Expert knowledge of complex claims principles and practices.
• Proficiency in claims handling systems, analytics tools, and databases.
• Strong understanding of multi-jurisdictional laws.
• Ability to apply technical knowledge and human relations skills to ensure fair and prompt management of cases.
• Skilled in negotiation, strategic decision-making, and mentoring.
• Advanced critical thinking skills and attention to detail.
• Excellent verbal and written communication skills, time management, and organizational skills required.

Nice To Haves

• Continuing education designations (CPCU, AIC, etc.) or other industry licensing and training programs are preferred.

Responsibilities

• Investigates and gathers necessary information to resolve assigned claims.
• Examines major and catastrophic claims to determine coverage, liability, and damages.
• Communicates with insureds to obtain information necessary for processing claims.
• Partners with legal counsel on litigation strategies while maintaining file ownership.
• Attends depositions and conferences exercising appropriate prioritization based on workload.
• Contacts and/or interview claimants, doctors, medical specialists, or employers to obtain relevant information.
• Conducts thorough investigations, including reviewing medical records, legal documents, and other supporting evidence.
• Directs additional investigation of questionable claims to determine compensability.
• Identifies potential fraud indicators and escalate as necessary.
• Applies technical knowledge and human relations skills to ensure fair and prompt management of cases.
• Manages and approves benefit payments within authority limits, ensuring compliance with state regulations and internal standards.
• Effectively communicates exposure and strategies to senior leadership.
• Resolves claims fairly and equitably, acting in the best interest of the insured and providing benefits as prescribed by law and in accordance with company standards.
• Utilizes structured settlements to resolve high exposure claims.
• Serves as a mentor and works closely with branch staff to devise strategy for reserving and settlement on high exposure claims, as requested.
• Identifies opportunities to engage with other company departments including managed care, legal, payment recovery, and SIU.
• Attends settlement mediations and conferences, as necessary.
• Participates in claim reviews and service calls with insureds and prospective insureds.
• Reduces and mitigates Company’s financial exposure.
• Researches historical billing data for facilities and providers to establish accurate file reserves.
• Analyzes and reports catastrophic and major claims loss data to WCC leaders.
• Implements proactive and strategic plans to bring claims to a timely and appropriate resolution.
• Anticipates future developments and exposures and maintain accurate reserves.
• Pursues subrogation in most cases; refers and/or follows up on subrogation efforts.

Benefits

• Challenging work and the ability to make a difference
• You will have a voice and feel a sense of belonging
• We offer a competitive benefits package, with generous medical, dental, and vision plans as well as 401K retirement plans and company match
• Bonus potential for all positions
• Paid Time Off
• Paid holidays throughout the calendar year
• Want to continue learning? We’ll support you 100%

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees