Claims Examiner - Brea, United States - eTeam

    eTeam
    eTeam Brea, United States

    1 month ago

    eTeam background
    Description
    Job Title: Claims Examiner - Workers Compensation
    Location: 100% Remote
    Duration: 3+ Months


    Description:
    • CA WC claims experience of 4+ years is required.
    • CA Adjuster certification preferred.
    PRIMARY PURPOSE:
    • To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.
    ESSENTIAL FUNCTIONS and 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 clams within designated authority level.
    • Prepares necessary state fillings 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 our 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.
    ADDITIONAL FUNCTIONS and RESPONSIBILITIES
    • Performs other duties as assigned.
    • Supports the organization's quality program(s).
    • Travels as required.
    QUALIFICATION
    Education & Licensing
    • Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.
    Experience
    • Five (5) years of claims management experience or equivalent combination of education and experience required.
    Skills & Knowledge
    • 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.
    • Excellent oral and written communication, 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