Workers Compensation Claims Examiner III (Hybrid)

## Workers Compensation Claims Examiner III (Hybrid)

**JOB SUMMARY:**

Investigates, evaluates, disposes and settles moderately complex to complex/high exposure claims. Includes the investigation, evaluation and determination of coverage, compensability and responsibility and the setting of proper reserves.

**DUTIES AND RESPONSIBILITIES:**

• Processes moderately complex to complex or high exposure claims consistent with clients’ and corporate policies, procedures and “Best Practices” and in accordance with any statutory, regulatory and ethics requirements.
• Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim working within established level of authority.
• Interacts with injured workers, client contacts and attending Physician(s) to ensure awareness and understanding of the Workers’ Compensation process, requirements and entitlements.
• Interacts with disability and leave examiners for coordination of non-occupational benefits.
• Prepares and issues notices in accordance with mandated requirements and regular reviews and stays abreast of applicable laws, rules and regulations that may impact on how claims are processed.
• Establishes and maintains proper reserving throughout the life of the claim.
• Identify subrogation potential and pursue the process for reimbursement.
• Complies with carrier excess reporting and threshold requirements.
• Coordinates medical treatment for injured workers and provides information to treating physicians(s) regarding the employee’s medical history, health issues and job requirements.
• Fully understands Medicare reporting requirements as they relate to a Workers’ Compensation claim.
• Facilitates early RTW through temporary, transitional, alternate, or modified work.
• Manages all medical aspects of a claim file with a focus on RTW and end of treatment.
• Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc. up to assigned authority.
• Monitors’ status and quality of work performed.
• Serves as a liaison between medical providers, employees, legal professionals, clients and vendors.
• Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop strategy.
• Enters and maintains accurate information in the claims management computer system.
• Clearly communicates concise action plans and present plans for moving the claim to resolution.
• Meets with clients to discuss on-going claims or review open claim inventory.
• Effectively controls expenses on all Workers’ Compensation claims.
• Mentors first level WC Examiners.
• All other duties as assigned.

**EQUIPMENT OPERATED/USED: Computer**, fax machine, copier, printer and other office equipment.
**SPECIAL EQUIPMENT OR CLOTHING: Appropriate** office attire.
## Qualifications
Education: High School Diploma or GED required: Bachelor’s degree in related field (strongly preferred) or equivalent combination of education and experience.
Experience: Three (3) to five (5) years of Workers’ Compensation Claims administration experience required working with self-insured and/or insured claims.
**Preferred Skills:**

• Demonstrated experience working with complex, high exposure and litigated WC claims.
• Appropriately licensed and/or certified in all States in which claims are handled. Multi-Jurisdiction experience is a (+).
• Bilingual Spanish is a (+)
• Able to work in a fast paced, high stress, changing environment.
• Strong analytical, critical thinking and problem-solving skills are required.
• Effective verbal and written communication skills required.
• Excellent planning, organizing and negotiation skills required.
• Attention to detail.
• Negotiation and interpretive skills necessary.
• Demonstrated knowledge of established claims strategy and mitigation techniques.
• Establishes and maintains effective working relationships with those contacted in the course of work.
• Proficiency with computers and technology – working knowledge of Microsoft Office application suite (MS Word, Excel, etc. and familiarity and experience using standard claims administration applications.
• Good interpersonal skills with an ability to work within a team environment.
• Able to effectively handle multiple priorities simultaneously.
• Works independently.

Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]

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| | **MENTAL AND PHYSICAL REQUIREMENTS** | | |

| | **1. MENTAL EFFORT** a. Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X Solve practical problems; variety of variables with limited standardization; interpret instructions. | | |