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.
Investigates claims to determine an injured workers entitlement to Workers Compensation benefits; Administers indemnity and medical benefits for valid Workers Compensation claims; manages a caseload of claims from inception to closing or settlement.
ESSENTIAL JOB RESPONSIBILITIES:
- Completes 3-point contact on new claims within 24 hours in order to obtain information necessary to make a compensability decision on the claim
- Establishes appropriate reserve levels based on financial exposure and updates reserves upon receipt of new information
- Directs assistant to properly pay indemnity benefits and Awards. Issue state-mandated benefit notices within the required timeframes
- Annotates, categorizes and addresses incoming mail on a daily basis
- Responds to questions and requests from the client
- Strong proficiency in keyboarding and data entry skills; most time spent in front of a computer entering text with applications.
- Must be able to type accurately, enter information into a computerized system
- This position reports to the Unit Manager
OPS RACI RESPONSIBILITIES:
- Three-point Contact
- Benefit Delivery
- CMR Compliance
- Diary Compliance
- Excess Reporting Compliance
- Closing Ratio/Inventory Reduction
- Significant Claims Activities
- Regular File Reviews
- Statutory Requirements
- Client Relations
- Continuous Improvement
- Client Training
OPS RACI ACCOUNTABILITIES:
- Penalties and E&Os
- BS / BA or Equivalent Work Experience
- 3 to 5 years
- Ability to prioritize multiple tasks and meet deadlines
- Excellent written and verbal skills
- Excellent customer service skills
- Workers Compensation law, policies and procedures
- Medical and legal terminology
- Integration with Medicare
ROUTINE DECISIONS AND FORMAL POLICY SETTING:
Decisions routinely made include:
- Analyzes information gathered from all sources to determine whether to accept, delay or deny a claim.
- Analyzes medical reports to determine whether benefits are due and/or make settlement recommendations to the client.
- Determines when an activity check or sub rosa would be warranted based on red flags noted on the claim.
- No formal responsibility; Policies associated with the jobs purpose and essential responsibilities are set by others