Claims Examiner Jobs in USA, CA, Brea | Rose International Job

Required Education:

• High School Diploma or equivalent

Preferred Education:

• Bachelor's Degree from an accredited college or university

Preferred Certifications/License:

• Professional certification as applicable to the line of business

Required Experience:

• 3+ years of California workers' compensation claims experience
• Experience managing litigated and high-exposure claims
• Strong knowledge of California workers' compensation laws and regulations
• Familiarity with Medicare offsets, Social Security offsets, and subrogation recoveries
• Strong investigation, documentation, and claim management skills

Position Overview:

To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.

Job Duties :

• Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
• Negotiates settlement of claims within designated authority.
• Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
• Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within the designated authority level.
• Prepares necessary state filings within statutory limits.
• Manages the litigation process; ensures timely and cost-effective claims resolution.
• Coordinates vendor referrals for additional investigation and/or litigation management.
• Uses appropriate cost containment techniques, including strategic vendor partnerships, to reduce the overall cost of claims for our clients.
• Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
• Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
• Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
• Ensures claim files are properly documented, and claims coding is correct.
• Refers cases as appropriate to supervisor and management.
• Only those lawfully authorized to work in the designated country associated with the position will be considered.
• Please note that all Position start dates and duration are estimates and may be reduced or lengthened based upon a client's business needs and requirements.

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