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ALOIS Solutions · 23 hours ago

Workers Compensation Claims Examiner

California, United States

Contract

Hybrid

Senior Level

5+ years exp

ALOIS Solutions is seeking a Workers Compensation Claims Examiner to analyze complex workers' compensation claims and ensure their timely resolution. The role involves negotiating settlements, managing litigation processes, and maintaining professional relationships with clients and claimants.

ConsultingHuman ResourcesStaffing Agency

Hiring Manager

Jaikumar J.

Responsibilities

Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution

Negotiates settlement of claims within designated authority

Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim

Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level

Prepares necessary state fillings within statutory limits

Manages the litigation process; ensures timely and cost effective claims resolution

Coordinates vendor referrals for additional investigation and/or litigation management

Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients

Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets

Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner

Communicates claim activity and processing with the claimant and the client; maintains professional client relationships

Ensures claim files are properly documented and claims coding is correct

Refers cases as appropriate to supervisor and management

Qualification

CA adjuster certificationClaims management experienceInsurance principles knowledgeAnalytical skillsCommunication skillsNegotiation skillsOrganizational skillsInterpersonal skillsTeamwork ability

Required

CA adjuster certification

3+ years of relevant experience

Bachelor's degree from an accredited college or university preferred

Five (5) years of claims management experience or equivalent combination of education and experience required

Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures 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 skills

Good interpersonal skills

Excellent negotiation skills

Ability to work in a team environment

Ability to meet or exceed Service Expectations