• Analyzes compensability, liability and management of complex claims by way of thorough investigation to determine accurate exposure of a claim including but not limited to application of Medicare Set Asides.
• Handles claims through diary management and well developed action plans to an appropriate and expedited resolution.
• Manages reserve adequacy by way of appropriate and timely calculation of claim reserves pursuant to Best Practice and Statutory Standards.
• Timely preparation of settlement authority, negotiation and settlement of claims within designated authority.
• Prepares accurate & timely issuance of benefits notices, required reports within statutory limits
• Accurate calculation and timely provision of benefits within statutory limit.
• Successful management of litigation process by collaborating efforts with defense attorney and ensures timely, cost effective resolution within Statutory Guidelines of the Rules, Practice & Procedures of the Workers’ Compensation Laws of California.
• Manages the litigation process; ensures timely and cost effective claims resolution.
• Appropriate application of cost containment techniques by way of vendor management, strategic vendor partnership.
• Successful management of claim recoveries by identification & pursuance of subrogation, UEBTF & Subsequent Injuries Benefits Trust Fund, Excess Reimbursement and Medicare Offsets.
• Issuance of timely initial and subsequent reports to excess carrier including but not limited to timely response to excess carrier.
• Communicates claim activity and process with the claimant and client as necessary. Participates in periodic Claim Reviews or other client meetings requested by the client.
• Train and direct Claims Assistants / Administrative Staff to meet goals and deadlines
• Appropriate medical management pursuant to Best Practices and accurate application of UR/IMR Process, AME/QME Process, MPN and other Statutory Rules & Regulations pursuant to the Workers’ compensation Laws of California.
• Effectively maintain professional client relationships.
• Ensures data integrity on claim files by properly documenting and updating correct information and claims coding.
• Strict application and adherence to Client Service Agreements.
• Performs other duties as assigned.

 

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.

 

 

Job Requirements for the WORKERS COMPENSATION CLAIMS EXAMINER:

 

• Bachelor's degree from an accredited college or university preferred.
• Self-Insurance Plan Certificate (SIP). Insurance related course work: CPCU, WCCA, WCCP, ARM
• 4850 experience
• Current with required educational / training hours
• Excellent oral and written communication skills including but not limited to presentation skills.
• In-depth knowledge of appropriate principles and laws pursuant to the California WC Laws Practices & Procedures, medical/disability management, SIU/Fraud, litigation rules, Medicare/CMS Rules and ethical issues.
• PC literate including Microsoft office products
• Detailed oriented and strong organizational skills
• Able to handle multiple tasks in a fast paced environment
• Analytical and interpretive skills
• Ability to work in a team environment, good interpersonal skills
• Ability to achieve high performance standards and/or exceed Service Expectations