A Claims Examiner evaluates insurance claims in accordance with applicable contracts and government regulations within their insurance type. Determines member eligibility and financial responsibility of the insurance company.
Saint Petersburg, FL Job Details 1 day ago Qualifications Customer communication Microsoft Excel Microsoft Outlook Caseload management Regulatory compliance in claims processing Workers' compensation insurance knowledge Data interpretation Insurance claims reserve management Legal compliance Technical Proficiency Managing litigation projects Full Job Description
COMPANY VALUE STATEMENTS
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POSITION SUMMARY
The Workers' Compensation Claims Examiner is responsible for managing an inventory of high-exposure, complex, and litigated Workers' Compensation claims for DecisionHR PEO clients, ensuring each claim is thoroughly investigated, properly reserved, and driven to the most cost-effective and timely resolution. This role serves as the primary claims contact for assigned client companies and injured employees, partnering closely with carriers, third-party administrators, adjusters, defense counsel, medical providers, and loss control representatives throughout the life of each claim. The Claims Examiner operates with a high degree of independence and accountability, combining technical claims expertise with proactive client communication, risk mitigation strategy, and return-to-work program coordination. This is an individual contributor role reporting to the Workers' Compensation Claims Manager.
ESSENTIAL FUNCTIONS
Claims Investigation & Intake Serve as the primary intake point for first reports of injury from client companies and injured employees; conduct employer-level investigations and process insurance claims to the carrier or TPA for handling in a timely and accurate manner. Interview claimants, witnesses, and client representatives to gather all pertinent information needed to support a complete and accurate claim investigation. Verify coverage applicability through the applicable insurance policy; confirm that the injury, incident, and parties are covered under the policy terms before proceeding with claim processing. Evaluate claimant remuneration to determine appropriate compensation amounts; prepare and submit wage statements to the carrier for calculation of average weekly wage and applicable benefits. High Exposure & Litigated Claim Management Manage an active inventory of high-exposure, complex, and litigated Workers' Compensation claims from intake through resolution, ensuring each claim is properly investigated, reserved, and driven toward the most advantageous and cost-effective outcome. Collaborate closely with carrier adjusters to ensure sound claim decisions, accurate reserve levels, financial accuracy, subrogation and recovery opportunities, appropriate medical management, and effective litigation management and action planning. Complete settlement evaluations for assigned claims; work with the adjuster and defense counsel to develop and execute negotiation strategies that achieve timely and cost-effective resolution. Coordinate assignment of telephonic or field nurse case managers and, where warranted, activity checks or surveillance, in coordination with the adjuster throughout the course of a claim. Return to Work & Loss Mitigation Coordinate and actively support the Return to Work program for assigned claims; work collaboratively with client companies, carriers, and medical providers to facilitate the earliest practical return to work for injured employees, reducing compensation costs and minimizing litigation potential. Work with Loss Control representatives to facilitate on-site investigation of large losses and emerging risk trends; conduct or coordinate on-site visits promptly following significant loss events, including visits with the injured employee where appropriate. Facilitate identification of potential fraud on assigned claims; develop and implement claim strategies that mitigate the organization's exposure to fraudulent filings, coordinating with the adjuster and outside resources as needed. Client Communication & Education Maintain consistent, proactive, and professional communication with assigned client companies throughout the life of each claim; provide timely updates at key claim development milestones and material changes until the claim is closed. Consult with clients and employees to obtain information required to complete investigations, support claim decisions, and facilitate timely claim filing and management. Assist client companies in developing a thorough understanding of the Workers' Compensation claims process, their obligations and responsibilities, and strategies to reduce future exposure and improve return-to-work outcomes. Assist clients in implementing risk reduction strategies based on loss experience trends, claim patterns, and loss control observations. Loss Monitoring & Reporting Participate in monthly loss experience monitoring with the WC Claims Manager; identify clients with poor or deteriorating loss experience and support the development of targeted loss prevention activity or relationship review recommendations. Provide monthly updates on all outstanding indemnity claims to the WC Claims Manager, including status, reserve accuracy, anticipated resolution timeline, and any material developments. Prepare and maintain accurate claim documentation, notes, and activity logs in the claims management system throughout the life of each claim. Continuing Education & Compliance Attend Workers' Compensation seminars, conferences, and continuing education opportunities to remain current on legal, medical, regulatory, and industry developments affecting the Workers' Compensation claims process. Maintain current knowledge of applicable state Workers' Compensation laws, claim handling requirements, classification systems, and multi-state compliance obligations relevant to DecisionHR's client portfolio. Follow company policies and procedures required to comply with applicable data privacy and confidentiality requirements, including but not limited to SOC controls and HIPAA Privacy and Security regulations. Other duties and responsibilities as assigned.
REQUIRED EDUCATION AND EXPERIENCE
Bachelor's degree in Business, Risk Management, Insurance, or a related field preferred; equivalent combination of education and directly relevant claims experience will be considered. 4-5 years of Workers' Compensation claims handling experience with multi-state knowledge, gained with a major insurer, insurance agency or broker, PEO, TPA, or as a private consultant. Comprehensive knowledge of Workers' Compensation laws, claim handling procedures, classifications, coding, and multi-state compliance requirements. Demonstrated experience managing high-exposure, complex, and litigated Workers' Compensation claims from intake through resolution. Experience collaborating with adjusters, defense counsel, and medical providers on reserve accuracy, settlement strategy, litigation management, and medical case management. Strong analytical and critical thinking skills; ability to evaluate loss data, assess exposure, and develop effective claim strategies. Excellent written and verbal communication skills; ability to communicate claim status and technical information clearly to clients, adjusters, counsel, and leadership. Proficiency in Microsoft Office Suite including Excel, Word, and Outlook; experience with claims management systems.
PREFERRED EDUCATION AND EXPERIENCE PEO
experience strongly preferred. Experience with Return to Work program coordination and light-duty placement strategies. Experience with fraud identification and coordinating fraud mitigation strategies with carriers and investigators. Familiarity with loss control principles and experience working alongside loss control representatives on large-loss investigations. Professional designation in Workers' Compensation or insurance claims (e.g., AIC, CPCU) preferred or actively pursued. Experience preparing loss experience reports and presenting findings to management or clients.
