Senior Claims Examiner

Athens Administrators•Concord, CA

9d•Hybrid

About The Position

Athens Administrators is hiring a full-time Senior Claims Examiner to support its California workers’ compensation offices. The role may be based anywhere in California. Employees who live within 26 miles of the Concord or Orange, California offices must work in the office once a week on a day set by their supervisor between Tuesday and Thursday; remaining days may be worked remotely if technical requirements are met and the employee resides in California. The schedule is Monday through Friday, 37.5 hours per week, with a flex-schedule option. Athens offices are open Monday through Friday from 7:30 a.m. to 5:30 p.m. local time. The Senior Claims Examiner adjusts 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, and negotiates settlements. It also provides direction, training, coaching, and mentoring to Claims Assistants and Claims Technicians as needed. The next career progression may include Lead Senior Claims Examiner or Claims Supervisor. Athens Administrators is a nationwide, family-owned claims administration company founded in 1976. It describes its culture as engaging, supportive, and inclusive, with opportunities for professional growth. The company emphasizes honesty and integrity, service and results, and a caring family culture.

Requirements

High school diploma or equivalent (GED).
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).
At least 3 years of recent workers’ compensation claims-handling experience.
Administrators Certificate from Self-Insurance Plans, or obtain it within one year of employment.
Knowledge of workers’ compensation laws, policies, and procedures.
Completion of IEA or equivalent courses.
Ability to determine case value and negotiate settlements.
Understanding of medical and legal terminology and mathematical calculation skills.
Well-developed verbal and written communication skills, attention to detail, strong 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, friendly approach to colleagues and clients.
Ability to reliably commute to meetings and events as required by the position.

Nice To Haves

Associate of Arts/Associate of Science or Bachelor of Arts/Bachelor of Science degree.
At least 5 years of workers’ compensation claims experience.

Responsibilities

Establish contact with employers to review claim issues and respond to inquiries from employers, employees, doctors, and attorneys.
Establish and maintain appropriate claim reserves.
Review legal correspondence, medical reports, and medical and legal bills for appropriateness.
Evaluate and approve medical procedures and treatment; discuss treatment appropriateness with medical case managers; and authorize and negotiate costs of medical treatment and supplies.
Administer benefits and ensure payments are appropriate.
Investigate coverage, liability, and claim value, and determine compensability.
Monitor and assist with litigation, collaborate with attorneys on settlement drafts and litigation strategies, and negotiate settlements, liens, and rehabilitation plans.
Prepare and present reports to clients, prepare professional written correspondence and other communications, and maintain internal communication with staff.
Close claims appropriately and help resolve client billing and payment inquiries.
Investigate complaints from injured workers.
Document and code claim files and claims systems with relevant information, and maintain and update action plans within specified time frames.
Provide direction to Claims Assistants and Claims Technicians and assist with their training, coaching, and mentoring as needed.
Communicate with employers, employees, attorneys, doctors, vendors, and other parties, and provide customer service and support to clients and claimants.

Benefits

Medical insurance
Vision insurance
Dental insurance
Life insurance
Accidental death and dismemberment coverage
Long-term care coverage
Critical care coverage
Accident coverage
Hospital indemnity coverage
Health savings account and flexible spending account options
401(k) and Roth 401(k)
Company-paid short-term disability and long-term disability
Eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments