WC Claims Examiner

Overview

Job Summary: Investigate workers compensation claims as assigned by claims supervisor, determine compensability of claim and liability based upon facts, applicable negligence laws, case law and statutes. Responsible for managing workers’ compensation claims as assigned by claims supervisor. Investigates claims. Determines the compensability of the claim and extent of liability. Communicates directly with clients, employers, injured workers, physicians, and attorneys to bring claims to a timely conclusion.

Job Summary: Investigate workers compensation claims as assigned by claims supervisor, determine compensability of claim and liability based upon facts, applicable negligence laws, case law and statutes. Responsible for managing workers’ compensation claims as assigned by claims supervisor. Investigates claims. Determines the compensability of the claim and extent of liability. Communicates directly with clients, employers, injured workers, physicians, and attorneys to bring claims to a timely conclusion.

Essential Duties and Responsibilities: Other duties may be assigned.

• Interviews, telephones, or corresponds with claimant and witnesses, consults police and hospital records.
• Documents all information from contacts with employers, claimants, physicians, and attorneys into the claims management system and ensures that documentation is current.
• Reviews claims submissions for thoroughness and accuracy.
• Determines compensability of claims through information gathered and according to workers’ compensation statutes; makes recommendations as to compensability and coverage of claims.
• Provides guidance and advice to clients on direction of claims after all information has been gathered and analyzed.
• Ensures jurisdictional filings are complete and timely.
• Obtains pre-certification approval for specific treatments as needed.
• Reviews bills and medical notes; authorizes and codes bills.
• Attends seminars and meetings as needed to stay abreast of current industry knowledge.
• May attend mediations, hearings, trials or other legal proceedings.
• Processes medical-only workers’ compensation claims involving minor injuries and/or payment.

• Education and/or
  
  Experience:
  
  A High School degree or equivalent is required. At least two years college credit from a four-year college or university; or an Associate’s degree from a two-year college; or an Associate in Claims designation from the Insurance Institute of America is preferred. This position requires a minimum of two years of workers’ compensation claims handling experience, client services skills and/or training.
• Certificates, Licenses, Registrations:
  Georgia Claims Adjuster license(s) as mandated by applicable state(s) are required. Current valid drivers’ license is required.
• Language
  
  Skills:
  
  The position requires the ability to read, analyze and interpret common technical journals, financial reports and legal documents, as well as the ability to respond to common inquiries or complaints from customers, state agencies or members of the business community. The employee must have the ability to effectively present information to management, employers, boards of directors and other committees, and have the ability to effectively interview claimants and other interested parties.
  
  The employee must have the ability to give presentations and attend client in-services. The employee must have the ability to communicate effectively through written correspondence.
• Mathematical
  
  Skills:
  
  Employee must have the ability to work with mathematical concepts and apply concepts such as percentages, fractions, ratios and proportions to practical situations.
• Reasoning Ability:
  Employee must have the ability to define problems, collect data, establish facts and draw valid conclusions; ability to interpret a variety of technical instructions and deal with several variables; ability to effectively negotiate claim settlements.

Candidate should be comfortable with an on-site presence to support collaboration, team leadership, and cross-functional partnership.

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