Job Description
Job DescriptionJob Profile Job Title: Claims ExaminerLocation: Plano, TX -must live in TXHire Type: Contingent Pay Range: $45/hr.Work Model: Remote/HybridWork Shift: Monday-Friday 8 am – 4:30 pm Recruiter Contact: Sean Craft I sean@marykraft.com I 443-345-3305 Nature & Scope:Positional OverviewWe are seeking an experienced Claims Examiner to manage complex and technically challenging workers' compensation claims. This role requires analyzing high exposure claims, including those involving litigation and rehabilitation, ensuring claims are adjudicated accurately and within service expectations, and identifying opportunities for subrogation and settlements. The ideal candidate will have a strong knowledge of California or applicable state workers’ compensation regulations, excellent negotiation skills, and the ability to maintain professional client relationships.Role & Responsibility:Tasks That Will Lead to Your Success
- Analyze and process complex workers' compensation claims by gathering and evaluating information to determine exposure.
- Manage claims through well-developed action plans to achieve timely and appropriate resolution.
- Negotiate settlements within designated authority.
- Calculate, assign, and manage reserves throughout the life of the claim.
- Approve and process claim payments and adjustments; ensure timely benefit distribution.
- Prepare required state filings within statutory limits.
- Oversee litigation processes to ensure cost-effective and timely claims resolution.
- Coordinate vendor referrals for additional investigation or litigation management.
- Apply cost containment strategies, including strategic vendor partnerships, to reduce overall claim costs.
- Manage claim recoveries, including subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.
- Report claims to excess carriers and respond to requests for direction in a professional and timely manner.
- Communicate claim activity and processing updates to claimants and clients while maintaining professional relationships.
- Ensure claim files are properly documented and coded accurately.
- Refer complex cases to supervisors or management as needed.
Skills & ExperienceQualifications That Will Help You Thrive
- High School Diploma or GED required.
- Professional certification relevant to line of business preferred.
- Minimum of 5 years of claims management experience or equivalent combination of education and experience.
- Expertise in insurance principles, laws, recoveries, offsets, and claim/duration management.
- Knowledge of cost containment strategies, medical management practices, and Social Security/Medicare procedures.
- Strong analytical, interpretive, and problem-solving skills.
- Excellent oral and written communication, including presentation skills.
- Proficiency with Microsoft Office and basic computer literacy.
- Strong organizational skills and ability to manage multiple tasks.
- Excellent negotiation and interpersonal skills.
- Ability to work effectively in a team environment and meet service expectations.
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