What are the responsibilities and job description for the Claims Examiner - Workers Compensation position at Rose International?
The client is looking for a candidate who can analyze complex or technically difficult CA 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.
Education & Experience
Bachelor''s degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.
Seven years of claims management experience or equivalent combination of education and experience required.
Indemnity & litigation experience is must.
SIP - preferred
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.
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
Only those lawfully authorized to work in the designated country associated with the position will be considered.
Please note that all Position start dates and duration are estimates and may be reduced or lengthened based upon a client’s business needs and requirements.
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