Claims Examiner

Worker's Compensation Claims Examiner III 2 Days onsite / 3 days remote Salary Range $80,000.00 - $83,000.00 Salary Level Experienced | Position Type Full Time | Job Shift Day | Category Insurance Must have SIP Here are some of the benefits you can enjoy in this role: Medical, Dental, Vision Insurance Life and Disability Insurance 401(k) match 45/50/55% (paid in 2025) 16 days PTO + Paid holidays (11 holidays + 2 floating holidays) Referral & Christmas bonuses

POSITION SUMMARY

At the Direction of the Claims Supervisor and/or Manager and under minimal supervision manages all aspects of litigated indemnity claims handling from inception to conclusion within established authority and guidelines. This position requires considerable interaction with clients, claimants, medical providers, Attorneys, vendors, Nurse and Vocational Case Managers, and other staff.

DUTIES AND RESPONSIBILITIES

Effectively manages a caseload of indemnity claim files, including very complex and litigated claims.

• Initiates and conducts investigations in a timely manner.
• Determines compensability of claims and administers benefits based upon state law and best practices for claim handling.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Refers cases to outside defense counsel and participates in litigated matters.
• Communicates with claimants, attorneys, providers and vendors regarding claims issues.
• Work in an organized and proactive manner.
• Computes and set reserves within Company guidelines.
• Settles and/or finalize all claims and obtains authority as designated.
• Maintains diary system for case review and documents file to reflect the status and work being performed on the file, including a plan of action.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns.
• Conducts file reviews as scheduled by the client and management.
• Identify and review claims for Apportionment assignment.
• Identify and investigate subrogation potential and pursue recovery.
• Identify claim standard criteria for excess reporting and reimbursement.
• Assist with State Audit and reporting responses.
• Mentors less experienced Examiners Other duties as assigned and including claims management of other jurisdictional workers' comp claims. Adheres to all company policies and procedures.
• Essential job function.

EQUIPMENT OPERATED/USED

C omputer, 10-key, fax machine, copier, printer, and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING

Appropriate office attire

QUALIFICATIONS REQUIRED

Education/Experience:

Minimum five (5) or more years related experience; or equivalent combination of education and experience.

Knowledge, Skills, and Abilities:

Technical knowledge of statutory regulations and medical terminology. Analytical skills. Excellent written and verbal communication skills, including ability to convey technical details to claimants, clients, and staff. Ability to interact with persons at all levels in the business environment. Ability to independently and effectively manage very complex claims. Proficient in Word and Excel (preferred).

Other Qualifications:

Licenses as required by Jurisdiction.

Pay:

$83,000.00 - $85,000.00 per year

Benefits:

401(k) matching Dental insurance Health insurance Life insurance Paid time off Vision insurance

Work Location:

Hybrid remote in Fresno, CA 93844