Claims Examiner III - Clayton Road Concord, California, United States

Description · Please make sure that you complete all the questions and navigate to the end of the application to sign the application. · JOB SUMMARY: · Investigates, evaluates, disposes, and settles moderately complex to complex/high exposure claims. Includes the investigation, e ...

Job description

Description

Please make sure that you complete all the questions and navigate to the end of the application to sign the application.

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

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 complex, high-exposure, and litigated WC claims.
• Appropriately licensed and/or certified in all States in which claims are handled. Multi-Jurisdiction experience is a (+).
• Bilingual Spanish is a (+)
• Able to work in a fast-paced, high-stress, changing environment.
• Strong analytical, critical thinking, and problem-solving skills are required.
• Effective verbal and written communication skills required.
• Excellent planning, organizing, and negotiation skills required.
• Attention to detail.
• Negotiation and interpretive skills are necessary.
• Demonstrated knowledge of established claims strategy and mitigation techniques.
• Establishes and maintains effective working relationships with those contacted in the course of work.
• Proficiency with computers and technology – working knowledge of Microsoft Office application suite (MS Word, Excel, etc. and familiarity and experience using standard claims administration applications.
• Good interpersonal skills with an ability to work within a team environment.
• Able to effectively handle multiple priorities simultaneously.
• Works independently.

Here are some of the benefits you can enjoy in this role:

• Medical, Dental, Vision Insurance.
• Life and Disability Insurance.
• 401(k) Plan 
• Paid Holidays
• Paid Time Off.
• Referral bonus.

Mental and Physical Requirements: [see separate attachment for a copy of the checklist of mental and physical requirements]

MENTAL AND PHYSICAL REQUIREMENTS

1.  MENTAL EFFORT

a Reasoning development:

Follow one- or two-step instructions; routine, repetitive task.

Carry out detailed but uninvolved written or verbal instructions; deal with a few concrete variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

 X      Solve practical problems; variety of variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve problems; several abstract and concrete variables.

Wide range of intellectual and practical problems; comprehend most obscure concepts.

b Mathematical development:

Simple addition and subtraction; copying figures, counting, and recording.

Add, subtract, multiply, and divide whole numbers.

 X       Arithmetic calculations involving fractions, decimals, and percentages.

Arithmetic, algebraic, and geometric calculations.

Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.

Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination, require theoretical application.

c Language development:

Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.

Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.

Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.

 X       Ability to compose original correspondence, follow technical manuals, and have increased contact with people.

Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

2.  PHYSICAL EFFORT

a Physical activity required to perform the job:

Sedentary work:  Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time.  Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

 X       Light work:

a.     Exerting up to 20 pounds of force occasionally

b.     Exerting up to 10 pounds frequently

c.     Exerting a negligible amount of force constantly to move objects

If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

Medium work:

a.     Exerting up to 50 pounds of force occasionally

b.     Exerting up to 20 pounds of force frequently

c.     Exerting up to 10 pounds of force constantly to move objects

Heavy work:

a.     Exerting up to 100 pounds of force occasionally

b.     Exerting up to 50 pounds of force frequently

c.     Exerting up to 20 pounds of force constantly to move objects

Very heavy work:

a.     Exerting in excess of 100 pounds of force occasionally

b.     Exerting in excess of 50 pounds of force constantly to move objects

c.     Exerting in excess of 20 pounds of force constantly to move objects

1. Visual requirements necessary to perform the job:

Far vision:  clarity of vision at 20 feet or more

 X      Near vision:  clarity of vision at 20 inches or less

 X       Mid-range vision:  clarity of vision at distances of more than 20 inches and less than 20 feet

Depth perception:  the ability to judge distance and space relationships, so as to see objects where and as they actually are

Color vision:  ability to identify and distinguish colors

Field of vision:  ability to observe an area up or down or to the right or left while eyes are fixed on a given point

2.  PHYSICAL EFFORT (cont.)

     FREQUENCY

c.     Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):

Climbing:      Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms.  Body agility is  emphasized.  This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.

Balancing:      Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces.  This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.

 X    Stooping:       Bending body downward and forward by bending spine at the waist.  This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.

 X    Kneeling:       Bending legs at knee to come to a rest on knee or knees.

 X    Crouching:    Bending the body downward and forward by bending legs and spine.

Crawling:      Moving about on hands and knees or hands and feet.

 X    Reaching:       Extending hand(s) and arm(s) in any direction.

 X    Standing: Particularly for sustained periods of time.

 X    Walking: Moving about on foot to accomplish tasks, particularly for long distances.

 X    Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.

 X    Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.

Foot

       Motion: Using feet to push pedals.

 X    Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position.  This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.

 X    Fingering:      Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.

 X    Grasping:       Applying pressure to an object with the fingers and palm.

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Frequently

Frequently

Occasionally

2.  PHYSICAL EFFORT (cont

       FREQUENCY

 X    Talking: Expressing or exchanging ideas by means of the spoken word.  Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

 X    Hearing: Perceiving the nature of sounds with or without correction.  Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts.

Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.

 X    Repetitive      Substantial movements (motions) of the wrists, hands,

       Motion: and/or fingers.

Frequently

Frequently

Frequently

3.  WORKING CONDITIONS

Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure. 

WORKING CONDITION

ENVIRONMENTAL

FACTOR

NATURE/REASON

OF EXPOSURE

FREQUENCY

Dirt/Dust

Noise

Temperature extremes

Dampness

Vibrations

Equipment movement hazard

Chemicals/solvents

Electrical shock

Significant work pace/pressure

Odors/Fumes