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Brea

    Claims Examiner - Brea, United States - NESCO Inc

    NESCO Inc
    NESCO Inc Brea, United States

    3 weeks ago

    Default job background
    Description

    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


    WORK ENVIRONMENT
    When applicable and appropriate, consideration will be given to reasonable accommodations.

    Mental:
    Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

    Physical:
    Computer keyboarding, travel as required

    Auditory/Visual:
    Hearing, vision and talking


    NOTE:
    Credit security clearance, confirmed via a background credit check, is required for this position.
    The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description
    They are not intended to constitute a comprehensive list of functions, duties, or local variances
    Management retains the discretion to add or to change the duties of the position at any time.

    Nesco Resource provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

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