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 position exists to independently reserve, manage, and bring complex Workers' Compensation claims to an equitable conclusion within the Company standards and best practices guidelines. The Claims Examiner will also oversee and delegate work to the Claim Assistants to ensure timely responses are made and that the work is accurate.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Investigates and gathers necessary information in order to settle assigned claims.
- Communicates with insureds to obtain information necessary for processing claims.
- Directs and manages legal counsel to ensure timely and cost-effective litigation.
- Attends depositions and hearings as often as workload allows.
- Contacts and/or interviews claimants, doctors, medical specialists, or employers to obtain necessary information to manage a claim.
- Examines claims investigated by outside adjusters, further investigating questionable claims to determine whether to authorize payments.
- Pursues subrogation, recoveries, and contribution vigorously and within statutory timeframes.
Applies technical knowledge and human relations skills to ensure fair and prompt management of complex cases.
- Presents cases and participates in their discussion at claim committee meetings.
- Creates and adjusts reserves in a timely manner to ensure reserving activities are consistent with company policies.
- Manages and approves payment of benefits within designated authority level.
- Resolves claims fairly and equitably, acting in the best interest of the insured while timely providing benefits to injured workers as required by law.
- Reports overpayments, underpayments, and other irregularities.
Assists in operational and administrative duties for the Claims department.
- Administers benefits to injured workers.
- Participates in claim reviews and service calls with insureds and prospective insureds.
- Ensures accuracy of data in claims system for compliance with applicable regulatory reporting.
- Ensures appropriate referral to preferred vendor partners to comply with cost containment procedures to reduce overall claim costs.
- Communicates effectively with other Company departments.
- Maintains a good working relationship with insureds, employers, agents, and other employees.
This role does not have direct reports but may mentor and/or train junior team members.
EDUCATION AND EXPERIENCE
High school diploma or general education degree (GED), required. Bachelor's degree from four-year college or university preferred with a major or emphasis in Business Administration, Management, Economics or related field. Minimum 3-6 years of related experience and/or training; or equivalent combination of education and experience.
CERTIFICATES, LICENSES, REGISTRATIONS
All Examiners must receive certification that meets the minimum standards of training, experience, and skill. WCCA and WCCP not required but helpful. State Workers Compensation License is required in some branches.
KNOWLEDGE AND SKILLS
Must have strong understanding of laws and jurisdictional restraints to manage injuries. Excellent verbal communication skills, time management and organizational skills. Requires a high level of attention to detail. Sense of urgency for execution.
Office environment – no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear.
This position maps to the Individual Contributor level. Additional competencies include: Problem Solving & Decision Making, and Influence.
This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment.