The Claims Examiner is responsible for the analysis and management of workers’ compensation claims. This position will review, investigate, and make decisions regarding coverage, compensability, and appropriateness of claims. This position will process and document claims to ensure compliance with company standards, industry best practices, and legislative provisions. Acts in a fiduciary role on behalf of policyholders, negotiates claim settlements and manages subrogation. Claims Examiners conduct the handling of claims in the utmost of good faith in compliance with the rules, regulations and statutes of the WCAB and State of California. The Claims Examiner is expected to function with a degree of competency. The use of sound judgment coupled with consistent results is expected.
- Analyzes and processes workers’ compensation claims by investigating and gathering information to determine the exposure on the claim.
- Negotiates settlement of claims up to designated authority level and makes claims payments.
- Calculates and assigns timely and appropriate reserves to claims and continues to manage reserve adequacy throughout the life of the claim.
- Calculates and pays benefits due; approves all claim payments; and settles claims within designated authority level.
- Develops and manages claims through well-developed action plans; continues to work the action plan to bring the claim to an appropriate and timely resolution.
- Prepares necessary state filings within statutory limits.
- Actively manages the litigation process; ensures timely and cost effective claims resolution.
- Coordinates vendor referrals for additional investigation and/or litigation management.
- Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims.
- Manages claim recoveries of all types, including but not limited to subrogation, Second Injury Fund recoveries, and Social Security offsets.
- Reports claims to the excess carrier, responds to requests of directions in a professional and timely manner.
- Frequently communicates with all appropriate parties involved with the claim.
- Refers cases as appropriate to management.
- Maintains professional client relationships.
- Actively executes appropriate claims activities to ensure consistent delivery of quality claims service.