We are always searching for Workers Compensation Claim Examiners in the California region to join our awesome team!
The purpose of this ad is to inform potential candidates about future career opportunities; this is not a job post.
Position Summary:
Administers and resolves non-complex short term claims of low monetary amounts, including medical only claims. Documents and monitors open case inventory and ensures proper and timely closing of files. Makes decisions on claims within delegated limited authority.
Responsibilities:
Conducts investigations of claims to confirm coverage and to determine liability, compensability, and damages. Works closely with claimants, witnesses and members of the medical profession and other persons pertinent to the investigation and processing of claims.
Verifies policy coverage for submitted claims and notifies the insured of any issues; determines and establishes reserve requirements, adjusting reserves, as necessary, during the processing of the claim.
Identifies wage loss expenses and wage exposures on medical claims.
Documents receipt and contents of medical reports. Interacts frequently with claimant to understand nature and extent of injury and medical conditions. Reviews and handles other correspondence within authority including material from the team members, and/or clients.
Approves payments of medical bills on lost time disability claims within area of payment authority up to, but not exceeding, $2,500 after compensability has been determined.
Evaluates medical claims for potential fraud issues, loss control and recovery in accordance with insurance policy contracts, medical bill coding rules and state regulations.
Keeps Team Manager informed verbally and in writing of activities and problems within assigned area of responsibility; refers matters beyond limits of authority and expertise to Team Manager for direction.
With the team managers guidance, provides input on the completion of status reports, initiate’s activity checks and/or widow’s statement of dependency forms.
Completes all reporting forms and file documentation.
Adheres to client and carrier guidelines and prepares written updates for supervisor to review.
Performs other related duties as required or requested.
