Claims Examiner III (Hybrid)

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JOB SUMMARY:

Investigates, evaluates, disposes, and settles moderately complex to complex/high exposure claims. Includes the investigation, evaluation, and determination of coverage, compensability, and responsibility, and the setting of proper reserves.

 DUTIES AND RESPONSIBILITIES:

• Processes moderately complex to complex or high exposure claims consistent with clients’ and corporate policies, procedures, and “Best Practices” and in accordance with any statutory, regulatory, and ethics requirements.
• Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim, working within the established level of authority.
• Interacts with injured workers, client contacts, and attending Physician(s) to ensure awareness and understanding of the Workers’ Compensation process, requirements, and entitlements.
• Interacts with disability and leave examiners for coordination of non-occupational benefits.
• Prepares and issues notices in accordance with mandated requirements and regular reviews and stays abreast of applicable laws, rules, and regulations that may impact how claims are processed.
• Establishes and maintains proper reserving throughout the life of the claim.
• Identify subrogation potential and pursue the process for reimbursement.
• Complies with carrier excess reporting and threshold requirements.
• Coordinates medical treatment for injured workers and provides information to treating physicians(s) regarding the employee’s medical history, health issues, and job requirements.
• Fully understands Medicare reporting requirements as they relate to a Workers’ Compensation claim.
• Facilitates early RTW through temporary, transitional, alternate, or modified work.
• Manages all medical aspects of a claim file with a focus on RTW and end of treatment.
• Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc., up to assigned authority.
• Monitors’ status and quality of work performed.
• Serves as a liaison between medical providers, employees, legal professionals, clients, and vendors.
• Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop a strategy.
• Enters and maintains accurate information in the claims management computer system.
• Clearly communicates concise action plans and presents plans for moving the claim to resolution.
• Meets with clients to discuss ongoing claims or review open claim inventory.
• Effectively controls expenses on all Workers’ Compensation claims.
• Mentors first-level WC Examiners.
• All other duties as assigned.

EQUIPMENT OPERATED/USED: Computer, fax machine, copier, printer and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire.

QUALIFICATIONS REQUIRED:

Education: High School Diploma or GED required: Bachelor’s degree in related field (strongly preferred) or equivalent combination of education and experience. 

Experience: Three (3) to five (5) years of Workers’ Compensation Claims administration experience required, working with self-insured and/or insured claims.

Preferred Skills:

• Demonstrated experience working with compl