Workers Comp Sr Claim Examiner

Certifies, administers and finalizes workers compensation claims with focus on advanced, large loss and complex claims. Reviews coverage's and secures information to determine liability and compensability. Analyzes fact of loss and injury information to determine exposure potentials. Manages caseload effectively.

1. Administers and manages large and complex active claims within workers compensation policies and guidelines.

2. Certifies or denies claims based on investigations by examiners, other departments, medical documentation, application of state statutes and rules, or third party recommendations.

3. Develops and manages action plans to facilitate resolution of claims; coordinates return-to-work efforts.

4. Ensures claim files are properly documented and correctly coded.

5. Determines if treatment is reasonable for the allowed condition. Assists in identifying or scheduling claims for independent medical or functional capacity exams.

6. Reviews reserves, sets reserves, and determines if reserves are appropriate for claim. Ensures claim reporting to excess carrier.

7. Reviews, evaluates and negotiates settlement of claims up to designated authority level.

8. Researches and applies basic state laws governing the handling of a claim and determines the best course of action needed to bring the claim to resolution.

9. Processes claims including calculation and payment of benefits due, as well as approval and timely payment of claim and adjustments. Files necessary documentation with appropriate state agency.

10. Identifies files for special investigation, subrogation and third party recovery potential.

11. Prepares strategy for the defense of denied claims and determines exposure potential for the settlement of claims. Works with legal counsel and assists with discovery.

12. Requests hearings and may attend trials and hearings as a representative of the company. Drafts and reviews motions or appeals as needed.

13. Participates in claim reviews.

14. High School diploma or equivalent required; Degree in a business related field preferred.

15. Minimum of four years workers compensation claims experience required.

16. Certification from a state recognized claims management program preferred.

17. Strong PC and Microsoft Office skills with proficiency in Word and Excel preferred.

18. Ability to learn and utilize claims management system required.

19. Excellent oral and written communication skills required.

20. Strong analytical, problem solving, and organizational skills, along with excellent customer service skills required.

21. Ability to multitask and consistently meet deadlines required.

22. Ability to travel on a limited basis required.

We will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws.