Claims Examiner (NE)
- 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.
Analyze workers compensation claims in order to produce a plan of action that will yield the best financial outcome for the customer.
Essential Duties and Responsibilities
All duties and responsibilities are essential job functions and are subject to possible modifications to reasonably accommodate individuals with disabilities.
- Initiate and implement workers compensation cost control strategies for a designated group of employers within preset guidelines. Cost control strategies include:
- Claim documentation
- Salary continuation
- Light duty or transitional work
- Lump sum settlement
- Handicap reimbursement
- Independent medical examinations
- Awareness of BWC discount programs
- Vocational rehabilitation
- Demonstrate excellent oral and written communication skills with both internal and external customers on a daily basis.
- Maintain customer satisfaction by frequently updating and educating employers on claim status and strategy. Occasional face-to-face meetings required.
- Build relationships with attorneys, MCO personnel, and BWC personnel.
- Explain specific claim issues to internal Rates Department staff so they can reply with an accurate actuarial analysis.
- Delegate tasks to claim assistants with clear instructions.
- Maintain accurate records regarding details of customer contact.
- Handle time-sensitive documents, phone calls, and tasks accurately and efficiently.
- Appeal BWC and IC orders within established timeframes.
- Return phone calls and emails within one business day.
- Complete daily tasks on system generated agenda.
- Thoroughly prepare claims for hearing on a weekly basis.
- Complete multiple action requests from Account Executives within one month.
- Monitors and maintains compliance with federal laws and rules, workers compensation laws and rules, and BWC contract requirements as applicable to areas of responsibility
- Identify areas for quality improvement and make recommendations to supervisor
- May be required to perform other job-related tasks other than those specifically presented above
Associate or Bachelors Degree in Health Care, Insurance or Legal field or equivalent work experience
A minimum of one year of professional experience
1-2 years of experience managing claims
Workers compensation experience as TPA Claims Examiner or MCO Case Specialist
Working knowledge or workers compensation rules and regulations
Customer service skills with excellent verbal and written communication
Ability to speak clearly and concisely
Proven research and documentation skills
Ability to prioritize and manage multiple tasks efficiently and within time frames
Professional presentation skills
Able to convey complex medical/claims information in a manner that others can understand
Identifies and recommends effective processes and procedures
Computer literate in Windows environment with ability to navigate between computer systems
Proficient in Excel and Word with ability to create basic spreadsheets
Experience with paperless imaging systems