Claims Examiner

South Portland, Maine

Posted: 11/27/2018 Industry: Insurance - Workers Comp Job Number: 2606
PRIMARY PURPOSE:  To analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES:

• Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.

• Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.

• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.

• Manages subrogation of claims and negotiates settlements.

• Communicates claim action with claimant and client.

• Ensures claim files are properly documented and claims coding is correct.

• May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.

• Maintains professional client relationships.

 

ADDITIONAL FUNCTIONS and RESPONSIBILITIES:

• Performs other duties as assigned.

• Supports the organization's quality program(s).

• Travels as required.

QUALIFICATIONS:

Education & Licensing

Bachelor's degree from an accredited college or university preferred.

Experience:

Four (4) years of claims management experience or equivalent combination of education and experience required.

 

Skills & Knowledge

•Working knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure 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 skill

•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.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

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