Claims Examiner - Workers Compensation
Company: Apidel Technologies
Location: Rancho Cucamonga
Posted on: January 19, 2023
PRIMARY PURPOSE: 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
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
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
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 clams within designated
Prepares necessary state fillings within statutory limits.
Manages the litigation process; ensures timely and cost effective
Coordinates vendor referrals for additional investigation and/or
Uses appropriate cost containment techniques including strategic
vendor partnerships to reduce overall cost of claims for our
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
Refers cases as appropriate to supervisor and management.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
Performs other duties as assigned.
Supports the organization's quality program(s).
Travels as required.
Education & LicensingBachelor's degree from an accredited college
or university preferred. Professional certification as applicable
to line of business preferred.
ExperienceFive (5) years of claims management experience or
equivalent combination of education and experience required.
Skills & Knowledge
Subject matter expert of appropriate insurance principles and laws
for line-of-business handled, recoveries offsets and deductions,
claim and disability duration, cost containment principles
including medical management practices and Social Security and
Medicare application procedures as applicable to
Excellent oral and written communication, including presentation
PC literate, including Microsoft Office products
Analytical and interpretive skills
Strong organizational skills
Good interpersonal skills
Excellent negotiation skills
Ability to work in a team environment
Ability to meet or exceed Service Expectations
When applicable and appropriate, consideration will be given to
Mental: Clear and conceptual thinking ability; excellent judgment,
troubleshooting, problem solving, analysis, and discretion; ability
to handle work-related stress; ability to handle multiple
priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding, travel as required
Auditory/Visual: Hearing, vision and talking
NOTE: Credit security clearance, confirmed via a background credit
check, is required for this position.
The statements contained in this document are intended to describe
the general nature and level of work being performed by a colleague
assigned to this description. They are not intended to constitute a
comprehensive list of functions, duties, or local variances.
Management retains the discretion to add or to change the duties of
the position at any time.
CA WC experience in past/present required.
Candidate has to be in CA and candidates MUST have California
licensing and experience.
Keywords: Apidel Technologies, Rancho Cucamonga , Claims Examiner - Workers Compensation, Other , Rancho Cucamonga, California
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