Senior Workers Compensation Claims Examiner

Cynet Systems•Long Beach, CA

About The Position

The candidate will analyze complex or technically difficult workers' compensation claims to determine benefits due. This role involves managing high exposure claims involving litigation and rehabilitation to ensure adjudication within industry best practices and specific service requirements. The primary purpose of this role is to analyze complex or technically difficult workers' compensation claims to determine benefits due. The candidate will work with high exposure claims involving litigation and rehabilitation, ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements, while identifying subrogation of claims and negotiating settlements.

Requirements

Five (5) years of claims management experience or equivalent combination of education and experience required.
Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices, and Social Security and Medicare application procedures as applicable to line-of-business.
Strong verbal and written communication skills, including presentation skills.
PC literate, including Microsoft Office products.
Analytical and interpretive skills.
Strong organizational skills.
Good interpersonal skills.
Excellent negotiation skills.
Ability to work in a team environment.
Ability to meet or exceed Service Expectations.

Nice To Haves

Bachelor's degree from an accredited college or university preferred.
Professional certification as applicable to line of business preferred.

Responsibilities

Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
Negotiates settlement of claims within designated authority.
Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
Prepares necessary state filings within statutory limits.
Manages the litigation process; ensures timely and cost effective claims resolution.
Coordinates vendor referrals for additional investigation and/or litigation management.
Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for the organization's clients.
Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.
Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
Ensures claim files are properly documented and claims coding is correct.
Refers cases as appropriate to supervisor and management.
Performs other duties as assigned.
Supports the organization's quality programs.
Travels as required.