Sr. WC Claims Examiner

Job Summary

Sr. Claims Examiner is 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.

• Interviews, telephones, or corresponds with claimant and witnesses; consults police and hospital records.
• Contacts physicians to obtain medical diagnoses and projected treatment plans.
• Monitors medical progress of claimants and coordinates follow-up treatments; reports to employers including any restrictions that may be imposed on claimants’ return to work.
• Documents all information from contacts with employers, claimants, physicians, and attorneys into the claims management system and ensures that documentation is current.
• Calculates and sets reserves through a reserve worksheet including the nature and scope of claims; adjusts reserves to reflect ultimate known exposures.
• Issues medical, indemnity, legal and expense payments.
• Prepares reports for excess carriers and requests reimbursement when needed.
• Sets reminders to follow-up on tasks through diaries on the system; reviews and completes diaries daily.
• Maintains physical files for claim-related documents such as medical information, legal reports, and other correspondence.
• 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.

• High School diploma or equivalent (required)
• Minimum of five (5) years’ experience handling complex workers’ compensation lost-time claims
• Multi-line experience (required)
• Experienced Workers’ Comp Claim Adjuster with active licensing
• Bilingual (Spanish) a plus
• Strong organizational skills, attention to details and the ability to multi-task and prioritize work
• Strong verbal, presentation, and written communication skills
• Strong computer skills including proficiency in Microsoft Word, Excel and Outlook
• Self-motivated and customer focused
• Attention to details and accuracy in documentation; maintain detailed and accurate records of claims
• Ability to establish and maintain good working relationships and rapport with others

This is a full-time position. Standard business hours of operation are Monday through Friday, 8:30 a.m. to 5 p.m.

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.

This description is not meant to be all-inclusive and may be modified from time to time at the discretion of management.

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

At Acrisure, we’re building more than a business, we’re building a community where people can grow, thrive, and make an impact. Our benefits are designed to support every dimension of your life, from your health and finances to your family and future.

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