Senior Claims Examiner

Athens Administrators • Agoura Hills, CA

10d • Hybrid

About The Position

Athens Administrators is hiring a full-time Senior Claims Examiner to support its workers’ compensation offices. The position must be located in Southern California and handles a dedicated school district account with monthly client reviews. The examiner manages workers’ compensation claims from inception through settlement and closure, including timely claim processing and benefit payments, medical treatment management, reserve setting, and settlement negotiation.

Employees who live less than 26 miles from the Orange, California office on The City Drive must work in the office once a week, on a Tuesday through Thursday selected by their supervisor. Other 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 an option for a flex schedule. Athens offices are open Monday through Friday from 7:30 a.m. to 5:30 p.m. local time.

The role includes communication with employers, employees, medical providers, attorneys, vendors, clients, and claimants; claim investigation and evaluation; benefit administration; litigation support; and client reporting. The examiner also provides direction, training, coaching, and mentoring to Claims Assistants and Claims Technicians as needed. Athens describes itself as a family-owned company founded in 1976, with an engaging, supportive, and inclusive culture and opportunities for professional growth.

Requirements

• High school diploma or GED required.
• 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 required within one year of employment if not already obtained.
• Completion of IEA or equivalent courses.
• Solid knowledge of workers’ compensation laws, policies, and procedures.
• 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, with strong attention to detail.
• Strong organizational skills and ability to multitask.
• Ability to type quickly, accurately, and for prolonged periods.
• Proficiency in Microsoft Office Suite and ability to learn additional computer programs.
• Reasoning, problem-solving, and analytical skills, including the ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions.
• Trustworthiness, dependability, teamwork, integrity, and a professional, friendly approach to colleagues and clients.
• Ability to seek innovative strategies and methods to provide a high level of service and results.
• 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.
• Ed Code experience preferred but not required.

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 and medical reports.
• Evaluate and approve medical procedures and treatment, and discuss treatment appropriateness with medical case managers.
• Administer benefits and ensure payments are appropriate; review medical and legal bills.
• Investigate claim coverage, liability, monetary value, and complaints from injured workers; determine compensability.
• Monitor and assist with litigation, including working with attorneys on settlement documents and litigation strategies.
• Negotiate claim settlements, liens, rehabilitation plans, and the cost of medical treatment and supplies.
• Prepare and present reports to clients, including participating in monthly client reviews.
• Help resolve client billing and payment inquiries; provide customer service and support to clients and claimants.
• Document and code claim files and claims systems with relevant information, maintain and update action plans within specified time frames, and close claims appropriately.
• Provide direction to Claims Assistants and Claims Technicians and assist with their training, coaching, and mentoring as needed.
• Communicate and collaborate with employers, employees, attorneys, doctors, vendors, other parties, and internal staff.
• Prepare professional 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 401(k)
• Company-paid short-term and long-term disability
• Eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments
• Opportunities for continuous professional growth

What This Job Offers

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