Senior Triage Claims Examiner

San Diego, California

 

PURPOSE OF THE JOB

The purpose of this job is to administer benefits to injured workers in accordance with statutory and case law as well as pertinent regulations. This job reserves manages and brings Workers Compensation claims to an equitable conclusion within the Company standards and best practices guidelines.

ESSENTIAL DUTIES AND RESPONIBILITIES

Administers benefits to injured workers

  • Communicates with insureds to obtain information necessary for processing claims.
  • Confers with legal counsel on claims requiring litigation.
  • Attends depositions and hearings as often as workload allows.
  • Contacts and/or interview claimants, doctors, medical specialists, or employers to get additional information.
  • Examines claims investigated by outside adjusters, further investigating questionable claims to determine whether to authorize payments.
  • Investigates, evaluates and settles claims, applying technical knowledge and human relations skills to ensure fair and prompt management of cases.
  • Pursues subrogation vigorously.
  • Participates in claim reviews and service calls with insureds and prospective insureds.
  • Manages and approve payment of benefits within designated authority level.
  • Presents cases and participate in their discussion at claim committee meetings.
  • Reports overpayments, underpayments and other irregularities.

Resolve claims fairly and equitably, acting in the best interest of the insured and providing benefits as prescribed by law.

Reserves, manages and brings Workers Compensation claims to an equitable conclusion

  • Creates and adjusts reserves in a timely manner to ensure reserving activities consistent with company policies.
  • Manages a regional unit of claim departments in the performance of their daily activities.

EDUCATION AND EXPERIENCE

High school diploma or general education degree (GED). Bachelors degree from four-year college or university preferred.

Requires a minimum of 1-3 years of work-related skill and knowledge.

CERTIFICATES, LICENSES, REGISTRATIONS

All Examiners must receive certification that meets the minimum standards of training, experience, skill and further education. Basic understanding of laws and jurisdictional restraints to manage injuries. WCCA and WCCP helpful. State Workers Compensation License is required in some branches.

KNOWLEDGE AND SKILLS

Excellent verbal and written communication skills, time management and organizational skills. Requires a high level of attention to detail. Team oriented and a sense of urgency for execution.

COMPETENCIES

This position maps to the Individual Contributor competency level. Additional competencies required: Problem Solving and Decision Making

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