Job Details

Analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.

Essential Functions/Responsibilities:

1. Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
2. Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
3. Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
4. Manages subrogation of claims and negotiates settlements.
5. Communicates claim action with claimant and client.
6. Ensures claim files are properly documented and claims coding is correct.
7. May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
8. Maintains professional client relationships.

Required Qualifications:

1. Bachelor's degree from an accredited college or university preferred.
2. Four (4) years of claims management experience.
3. Working knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure as applicable to line of business.
4. Excellent oral and written communication, including presentation skills.
5. PC literate, including Microsoft Office products.
6. Analytical and interpretive skills.
7. Strong organizational skills.
8. Good interpersonal skills.
9. Excellent negotiation skills.
10. Ability to work in a team environment.
11. Ability to meet or exceed Service Expectations.

Additional:

1. SIP a plus - Must be in California, remote in CA.
2. Min 3+ years as indemnity examiner handling CA Claims WC experience required.