Senior Claims Examiner - Remote or Hybrid in CA

Athens Administrators • Sacramento, CA

6d • Hybrid

About The Position

Athens Administrators is hiring a full-time Senior Claims Examiner to handle California workers’ compensation claims from inception through settlement and closure. The role ensures timely claim processing and benefit payments; manages and directs medical treatment; establishes reserves; investigates coverage, liability, compensability, and claim value; and negotiates settlements. The position also supports clients and claimants, coordinates with employers, employees, attorneys, medical providers, vendors, and other parties, and provides direction and coaching to Claims Assistants and Claims Technicians.

The role may be based anywhere in California. Employees living less than 26 miles from the Concord, California, or Orange, California, offices must work in the office once per week on a day selected by their supervisor between Tuesday and Thursday. Other workdays may be remote if technical requirements are met and the employee resides in California. The schedule is Monday through Friday, 37.5 hours per week, with an optional flexible schedule. Athens offices are open Monday through Friday from 7:30 a.m. to 5:30 p.m. local time.

The role requires a high school diploma or GED and at least three years of recent workers’ compensation claims-handling experience. An associate or bachelor’s degree is preferred but not required. The successful candidate must have a current Experienced Indemnity Claims Adjuster Designation and, if not already obtained, must earn an Administrators Certificate from Self-Insurance Plans within one year of employment. The position reports to a Claims Supervisor. The next career progression may include Lead Senior Claims Examiner or Claims Supervisor.

Requirements

• High school diploma or equivalent (GED).
• At least 3 years of recent workers’ compensation claims-handling experience.
• Current Experienced Indemnity Claims Adjuster Designation, provided by an insurer, as defined in California Code of Regulations, Title 10, Chapter 5, Subchapter 3, Section 2592.01(f).
• Administrators Certificate from Self-Insurance Plans required within one year of employment if not already obtained.
• Solid knowledge of workers’ compensation laws, policies, and procedures.
• Completion of IEA or equivalent courses.
• Proficiency in determining case value and negotiating settlements.
• Understanding of medical and legal terminology and mathematical calculation skills.
• Well-developed verbal and written communication skills, with strong attention to detail.
• Excellent organizational skills and ability to multitask.
• Ability to type quickly and accurately for prolonged periods.
• Proficiency in Microsoft Office Suite and ability to learn additional computer programs.
• Reasoning, problem-solving, and analytical skills, including researching and analyzing facts, identifying issues, and recommending appropriate solutions.
• Trustworthiness, dependability, teamwork, integrity, and a professional, service-oriented approach.
• Ability to reliably commute to meetings and events as required.

Nice To Haves

• Associate of Arts/Associate of Science or Bachelor of Arts/Bachelor of Science degree (preferred but not required).
• At least 5 years of workers’ compensation claims experience (preferred).

Responsibilities

• Establish contact with employers to review claim issues and respond to inquiries from employers, employees, doctors, attorneys, and other parties.
• Review legal correspondence and medical reports; evaluate and approve medical procedures and treatment.
• Administer benefits and ensure payments are appropriate; review medical and legal bills for appropriateness.
• Investigate coverage, liability, claim value, and complaints from injured workers; determine compensability.
• Establish and maintain appropriate reserves and action plans within specified time frames.
• Discuss medical treatment appropriateness with medical case managers and authorize or negotiate the cost of medical treatment and supplies.
• Monitor and assist with litigation, including collaborating with attorneys on settlement drafts and litigation strategies.
• Negotiate claim settlements, liens, rehabilitation plans, and other resolutions.
• Prepare and present reports to clients and help resolve client billing and payment inquiries.
• Document and code claim files and claims systems with relevant information, and appropriately close claims.
• Provide direction to Claims Assistants and Claims Technicians, assisting with their training, coaching, and mentoring as needed.
• Provide customer service and support to clients and claimants and communicate internally with staff.
• Prepare professional, well-written correspondence and other communications.

Benefits

• Medical, vision, and dental plans.
• Life and AD&D insurance.
• Long-term care, critical care, accident, and hospital indemnity plans.
• HSA and FSA options.
• 401(k) and Roth plans.
• Company-paid short-term and long-term disability coverage.
• Eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments.

What This Job Offers

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