Claims Examiner II
- Career Level
- Experienced (Non-Manager)
Investigates, evaluates, negotiates and settles claims in accordance with Montana State Fund Claim Guidelines and industry Best Claim Practices. Calculates and authorizes payment of medical and wage loss benefits. Assigns, directs and monitors rehabilitation and medical case management activities in accordance with the Claim Guidelines and industry Best Claim Practices. Runs II reports as needed to document medical, pharmacy and indemnity expenditures on claims.
Identifies and performs claims management activities to mitigate negative trending and/or meet team needs with regard to claim and/or account management including service as a team representative to industry groups.
Participate in companywide projects both on a voluntary basis and as requested.
Participate in large loss and catastrophic claim meetings to review, advise, and develop plans of action, review reserve adequacy, and to recommend resources needed to address key claim issues.
- Investigates, evaluates, negotiates, and resolves assigned claims in accordance with the MSF Claim Guidelines and industry Best Claim Practices
- Calculates and authorizes payment of medical and indemnity benefits within limits of authority and according to Montana Code Annotated (MCA) and fee schedules.
- Appropriately handles policyholder and injured worker confidential information according to MSF policies.
- Manage diary and complete activities and tasks to ensure that claims move to the best outcome and timely resolution.
- Demonstrate ability to successfully manage vendors in course of claim management.
- Analyze liability issues and determine exposure to properly set claim reserves.
- Obtain all necessary and pertinent claim file documents to achieve thorough work file documentation.
- For all assigned claims, and within timeframes outlined in the MSF Claim Guideline and industry Best Claim Practices, identify, document and implement the claim strategy and steps to achieve resolution of each assigned claim.
- Demonstrate consistent sound decision-making for all aspects of claim handling including reserve and settlement decisions.
- Coordinate the assignment and management of expert resources to assist in case resolution. Includes, but not limited to, peer review, legal resources, nurse case management, vocational rehab, designation of primary care provider, and/or other appropriate resources.
- Thoroughly investigate, evaluate, & present findings on potential catastrophic claims.
- Prepare annual reserve updates and a plan of action for all assigned claims including presentation of same to designated claim experts on all catastrophic and large loss claims.
- Continuously seek and accept claim management feedback in support of in the MSF Claim Guidelines and industry Best Claim Practices.
- Attend, participate, and demonstrate understanding and application of training on applicable Montana Workers’ Compensation statutes and Montana Code annotated, case law, as well as in the MSF Claim Guidelines, systems, and policies and industry Best Claim Practices.
- Establish and maintain productive relationships with assigned accounts. Manage customer relations and coordinate additional support when escalation requires such.
- Respond to injured worker and policyholder inquiries, adequately explain the workers’ compensation claim process in lay terms, and assist the injured worker and policyholder to understand the claim handling process throughout the life of the claim.
- Demonstrate professional business communications and behaviors, and customer service skills with internal and external customers.
- Develop and maintain positive working relationships with injured worker attorneys, medical providers and vendors.
The Duties below are in addition to those required of a CE I
- Provide claim expertise and policy oversight to lower level claim examiners and peers as requested.
- Present feedback and strategic recommendations in a positive manner.
- Identify policyholder claim trends and/or issues.
- Perform activities to mitigate negative claim trending and/or meet policyholder needs with regard to claim and/or policy management.
- Attend mediations, depositions, and court appearances, and assist in development of mediation and litigation management as needed for own claims as well as assisting lower level examiners.
- Participate in assigned companywide project/tasks/initiatives as assigned with emphasis on team and organizational goals/results.
- Is able to run and utilize position specific reports.
- Provides coaching and mentoring to Claim Examiner Trainees and other Claims Examiners either as part of formal or informal mentoring relationship as requested by their Claims Manager.