Examiner, Workers Compensation Claims
- Career Level
- Not Specified
York Risk Services Group is a premier provider of insurance, risk management, alternative risk, pool administration and claims management solutions to clients across hundreds of industries. Recently named by Forbes as one of "America's Best Midsized Companies 2017" We firmly believe that our employees drive the success of the company. With success in mind as the ultimate goal, we strive to create and provide an environment that offers challenging, stimulating and financially rewarding opportunities.
A Workers Compensation Claims Examiner is an experienced claims examiner who works under only general supervision and utilizes his or her training to review, examine, investigate, analyze and resolve workers compensation claims. As set forth in greater detail below, the examiners primary duties are interviewing witnesses and assessing credibility; reviewing factual information to prepare disability and future medical estimates; evaluating and making recommendations regarding coverage of claims; determining liability and total value of a claim; negotiating settlements; and making recommendations regarding litigation.
This position functions with a high level of claim-management and financial autonomy and performs a variety of complex technical duties within the general limitations of State Workers Compensation laws, Yorks best practices, and client service instructions.
Essential Duties and Responsibilities
All duties and responsibilities are essential job functions and are subject to possible modifications to reasonably accommodate individuals with disabilities.
Reviews, examines, investigates, analyzes and resolves workers compensation claims;. Develops strategic action plans to bring claims to prompt and equitable resolution. Identifies key interested parties and obtains recorded statements as necessary.
Assesses witnesses credibility.
Analyzes and resolves conflicts in the evidence.
Determines claim compensability based on witness statements and other evidence.
Establishes appropriate reserve levels based on his/her estimate of financial exposure and updates reserves upon receipt of new information within the even greater financial authority afforded to Senior Workers Compensation Claims Examiners. Accepts or delays claims and makes recommendations to manager regarding claim denials. Accurately determines average weekly wages and workers compensation benefit rates and pays benefits timely. Directs Claims Assistant(s) to issue notices and makes payments in accordance with State mandated requirements. Interacts with injured employees to ensure awareness and understanding of the workers compensation process, requirements and statutory benefits. Coordinates medical treatment for injured employees and interacts with medical providers regarding employees medical history and job requirements. Assesses subrogation potential and pursues reimbursement. Negotiates claim settlements within established limits.
Weighs the costs and benefits of going to trial versus entering into a settlement and chooses the most effective option.
Presents the settlement recommendations to client(s) if required.
Independently resolves liens without defense attorney involvement.
Serves as a liaison between medical providers, claimants, legal professionals and clients. Informs clients of injured employees work restrictions and coordinates appropriate accommodations. Reviews medical reports to ensure that the appropriate American Medical Association (AMA) guidelines have been applied when rating permanent impairment. Communicates with defense attorneys and clients on litigated cases and develops strategies for claim resolution. Litigation Management:
Decides when to retain counsel.
Develops litigation strategy with counsel.
Supervises the litigation process.
Prepares or reviews legal documents for submission to the Workers Compensation Board.
Manages all discovery requests by the defense attorney.
Attends and participates in hearings when requested.
Audits incoming invoices and/or bills for accuracy and appropriateness. Processes treatment requests in line with applicable state mandated Utilization Review standards. Coordinates with field investigators when conducting compensability, subrogation or subrosa investigations. Prepares claim status reports and presents to clients. Complies with excess insurance reporting requirements and seeks reimbursement where appropriate. Seeks reimbursement from codefendants or subsequent injury funds. Identifies and reports all suspected fraudulent activity to the appropriate authorities and/or state agencies. Complies with Medicare Set Aside obligations. Stays abreast of applicable laws, new trends, pending legislation and case law related to workers compensation. Manages outgoing payments in a timely manner. Maintains the required continuing education hours where applicable. Effectively manages client and other communications and maintains claim notes and status reports timely and accurately. Annotates, categorizes and addresses incoming mail and/or facsimiles on a daily basis. Performs other related duties as required.
BS/BA or Equivalent Work Experience
Professional certification and/or adjusting license as required by the State(s)
- 2 to 5 years of relevant experience
- High School Diploma
- Adjuster License or Certification if jurisdictionally required
- CPCU/ARM Designation
- Other Industry recognized designations e.g. Insurance Institute of America, Insurance Educational Association
A minimum of 2 years of Workers Compensation claims adjusting experience is desired.
Three to five years of Workers Compensation claims adjusting experience is preferred.
- Requires only general supervision
- Exercises sound judgment and critical thinking
- Meets or exceeds closing ratio objectives
- Incurs no penalties
- Effectively negotiates settlements
- Has effective analytical and interpretive skills
- Responsibly allocates significant reserve and payment authority
- Functions well in a team environment
- Strong customer service skills
- Proficient in typing and computer skills
- Effective communication management skills
- Possesses good time management and organizational skills
- Maintains and is current on all diaries
- Performs within the general guidelines of Yorks best practices, client special instructions, and internal and external audit requirements
- Has some team lead experience
- Demonstrates the ability to share knowledge
- Has special expertise in complex technical areas such as: award calculations, PD rating, structured settlements, catastrophic claims management, MSA etc.
- Conducts thorough investigations
- Has knowledge of statutory time frames and benefits
- Computes benefits timely and accurately
- Establishes and maintains accurate reserves
- Recognizes key issues
- Develops strategic action plans
- Knowledge of statutory form filing requirements
- Performs compensability evaluation and determination
- Proficiency in AMA Guides Impairment Rating or other jurisdictionally required impairment/PD schedules
- Possesses knowledge of medical management timeframes and dispute resolutions where applicable
- Identifies and coordinates early return to work accommodations
- Knowledge and experience with recorded statements
- Advanced knowledge and application of AMA Guides
- Knowledge of significant case law
- Complex issue recognition
- Advanced knowledge of medical terminology and identification of complex medical conditions
- Knowledge of structured settlements
- Knowledge of Medicare Set Aside requirements
- Proficiency with Microsoft Office and relevant claims management systems