Senior Claims Examiner

Athens Administrators•Concord, CA

2d•Hybrid

About The Position

Athens Administrators is hiring a full-time Senior Claims Examiner to handle workers’ compensation claims from inception through settlement and closure. The role ensures timely claim processing and benefit payments, manages and directs medical treatment, sets reserves, and negotiates settlements. The position supports the company’s workers’ compensation operations and may be based anywhere in California. Employees living within 26 miles of the Concord, California, or Orange, California, offices must work in the office once a week on a supervisor-designated day from Tuesday through 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, 7:30 a.m. to 5:30 p.m. local time. The Senior Claims Examiner works with employers, employees, medical providers, attorneys, vendors, clients, and internal staff to investigate, evaluate, administer, and resolve claims. The position also provides direction and support to Claims Assistants and Claims Technicians, including training and mentoring as needed. The role 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).
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 ability to obtain it within one year of employment.
Completion of IEA or equivalent courses.
Solid knowledge of workers’ compensation laws, policies, and procedures.
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 and strong 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 making appropriate recommendations and solutions.
Ability to be trustworthy, dependable, and team-oriented; to demonstrate care and concern for colleagues and clients professionally; and to act with integrity, including when handling confidential, proprietary, and sensitive information.

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, 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 the cost of medical treatment and supplies.
Administer benefits and ensure payments are appropriate.
Investigate coverage, liability, claim value, and complaints from injured workers; determine compensability.
Monitor and assist with litigation, including working with attorneys on settlement drafts and litigation strategies.
Negotiate settlements, liens, rehabilitation plans, and other claim matters.
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, maintain action plans within specified time frames, and appropriately close claims.
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, other parties, and internal staff.
Provide customer service and support to clients and claimants.
Prepare professional, well-written correspondence and other communications.
Reliably commute to meetings and events as required by the position.