Claims Examiner

Job Description

Job Title: Claims Examiner

Location: New Haven, CT

Duration: 3 Months (CTH)

Job Description:

• 3+ years of Workers’ Compensation Claim Examiner or Commensurate Experience (Having experience in workers’ compensation is not a requirement, but a nice thing to have, as long as the skills they do have are transferable.)

DUTIES AND RESPONSIBILITIES:

• Handles all aspects of workers’ compensation claims from set-up to case closure, ensuring strong customer relations are maintained throughout the process.
• Reviews claim and policy information to provide background for investigation.
• Conducts 3-part ongoing investigations, obtaining facts and taking statements as necessary, with insured, claimant, and medical providers.
• Evaluates the facts gathered through the investigation to determine compensability of the claim.
• Informs insureds, claimants, and attorneys of claim denials when applicable.
• Prepares reports on investigations, settlements, denials of claims, and evaluations of involved parties, etc.
• Timely administration of statutory medical and/or indemnity benefits throughout the life of the claim.
• Sets reserves within authority limits for medical, indemnity, and expenses and recommends reserve changes to the Team
• Leader throughout the life of the claim.
• Reviews the claim status at regular intervals and makes recommendations to the Team Leader to discuss problems and remedial actions to resolve them.
• Prepares and submits to the Team Leader unusual or possible undesirable exposures when encountered.
• Works with attorneys to manage hearings and litigation
• Controls and directs vendors, nurse case managers, telephonic case managers, and rehabilitation managers on medical management and return to work initiatives.
• Comply with customer service requests, including Special Claims Handling procedures, file status notes, and claim reviews.
• Files workers’ compensation forms and electronic data with states to ensure compliance with statutory regulations.
• Refers appropriate claims to subrogation and secures necessary information to ensure that recovery opportunities are maximized.
• Works with in-house Technical Assistants, Special Investigators, Nurse Consultants, and Telephonic Case
• Managers as well as Team Supervisors to exceed customers' expectations for exceptional claims handling service.

TECHNICAL SKILLS & COMPETENCIES:

• Claim Examiner position with prior experience in workers’ compensation as a claim examiner, or commensurate examiner experience in paralegal, short-term/long-term disability, auto personal injury protection / medical injury, general liability, medical billing, or as a claim technical assistant for lost time claims.
• Requires knowledge of workers’ compensation statutes, regulations, and compliance.
• Ability to incorporate data analytics and modeling into daily activities to expedite fair and equitable resolution of claims and claim issues.
• Exceptional customer service and focus.
• Ability to openly collaborate with leadership and peers to accomplish goals.
• Demonstrates a commitment to a career in claims.
• Exceptional time management and multi-tasking capabilities with consistent follow-through to meet deadlines.
• Use analytical skills to find mutually beneficial solutions to claims and customer issues.
• Ability to prepare and make exceptional presentations to internal and external customers.
• Conscientious about the quality and professionalism of work products and relationships with co-workers and clients.
• Willing to take ownership and tackle obstacles to meet Client's quality standards for service, investigation, reserving, inventory management, teamwork, and diversity appreciation.
• Superior verbal and written communication skills.

EXPERIENCE, EDUCATION & REQUIREMENTS:

• Experience working in a customer-focused, fast-paced, fluid environment
• Experience utilizing strong communication and telephonic skills
• Prior experience requiring a high level of organization, follow-up, and accountability
• Prior workers’ compensation claim handling experience is a plus, but not required
• Familiarity with claim handling (healthcare, short-term/long-term disability, auto personal injury protection / medical injury, medical billing, or general liability) is a plus, but not required
• Prior insurance, legal, or corporate business experience is a plus but not required
• AIC, RMA, or CPCU completed coursework or designation(s) is a plus but not required
• Proficiency with Microsoft Office Products
• Knowledge of medical terminology is a plus, but not required
• Knowledge of bill processing is a plus, but not required
• Claim Adjuster licenses in Connecticut, New Hampshire, Rhode Island, and Vermont are necessary; however, they are not required at the time of posting for the position.
• If you do not already have one, you will be required to obtain an applicable resident or designated home state adjuster's license and possibly additional state licensure.