[Hiring] Senior Workers Compensation Claims Examiner @Cynet Systems

Role Description

The primary purpose of this role is to analyze complex or technically difficult workers' compensation claims to determine benefits due, work with high exposure claims involving litigation and rehabilitation, ensure ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements, and identify subrogation of claims and negotiate settlements.

• Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine exposure, managing claims through well-developed action plans toward an appropriate and timely resolution.
• Negotiates settlement of claims within designated authority.
• Calculates and assigns timely and appropriate reserves to claims, managing reserve adequacy throughout the life of the claim.
• Calculates and pays benefits due, approving and making timely claim payments and adjustments, and settling claims within designated authority level.
• Prepares necessary state filings within statutory limits.
• Manages the litigation process to ensure timely and cost-effective claims resolution.
• Coordinates vendor referrals for additional investigation and litigation management.
• Uses appropriate cost containment techniques, including strategic vendor partnerships, to reduce the overall cost of claims for clients.
• Manages claim recoveries, including subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.
• Reports claims to the excess carrier and responds to requests or directions in a professional and timely manner.
• Communicates claim activity and processing with the claimant and the client, maintaining professional client relationships.
• Ensures claim files are properly documented and claims coding is correct.
• Refers cases as appropriate to supervisor and management.

Qualifications

• Bachelor's degree from an accredited college or university preferred.
• Professional certification as applicable to line of business preferred.

Requirements

• Five years of claims management experience or equivalent combination of education and experience required.

Skills & Knowledge

• Subject matter expert in appropriate insurance principles and laws for the line of business handled, recoveries, offsets, deductions, claim and disability duration, cost containment principles including medical management practices, and Social Security and Medicare application procedures.
• Strong verbal and written communication skills, including presentation skills.
• PC literate, including Microsoft Office products.
• Strong analytical and interpretive skills.
• Strong organizational skills.
• Good interpersonal skills.
• Excellent negotiation skills.
• Ability to work effectively in a team environment.
• Ability to meet or exceed service expectations.