Claims Examiner - Workers Compensation

Location : Brea, CA / Remote

Duration : 3 Months

Description : Primary purpose :

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 settlements.

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 resolution.

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 authority level.

Prepares necessary state fillings within statutory limits.

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 for our clients.

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 correct.

Refers cases as appropriate to supervisor and management.

Additional Functions and Responsibilities

Performs other duties as assigned.

Supports the organization's quality program(s).

Education Level : High School Graduate / GED

Qualification

Education & Licensing Bachelor’s degree from an accredited college or university preferred.

Professional certification as applicable to line of business preferred.

Experience Five (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 line-of-business.

Excellent oral and written communication, including presentation skills 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

Work Environment

When applicable and appropriate, consideration will be given to reasonable accommodations.

Requirements :

Prior 4850 experience along with min 2 years of CA claims handling experience is required.

SIP is mandatory

As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.