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.