Claims Examiner
Workers' Compensation Claims Examiner III 100% REMOTE – Must Reside in California Salary Range $90,000.00 - $100,000.00 Salary Level Experienced | Position Type Full Time | Job Shift Day | Category Insurance CA SIP License Required POSITION SUMMARY: Under minimal supervision, manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines. This position requires considerable interaction with claimants, medical providers, attorneys, vendors, management, and other claims staff. Consistent and timely attendance is inherently required for this position. DUTIES AND RESPONSIBILITIES:
- Effectively manages a caseload of 150–180 workers' compensation claim files, including very complex claims.
- • Initiates and conducts investigations in a timely manner.
- • Determines compensability of claims and administers benefits based upon state law and established guidelines.
- • Manages medical treatment and medical billing, authorizing as appropriate.
- • Refers cases to outside defense counsel and directs and manages litigation activities as appropriate.
- • Communicates with claimants, providers, attorneys, and vendors regarding claim issues.
- • Computes and sets reserves within established authority and guidelines.
- • Settles and/or finalizes all claims and obtains authority as designated.
- • Maintains a diary system for case review and documents files to reflect claim status and work being performed.
- • Communicates appropriate information to stakeholders to facilitate efficient claim resolution, including injury trends and safety-related concerns when applicable.
- • Conducts file reviews independently.
- • Adheres to all policies and procedures.
- • Other duties as assigned.
- Essential job function.
EQUIPMENT OPERATED/USED: Computer, 10-key, fax machine, copier, printer, and other office equipment. SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire. QUALIFICATIONS REQUIRED: Education/Experience: Bachelor’s degree in a related field (preferred); five (5) or more years of workers’ compensation claims experience; or equivalent combination of education and experience. Knowledge, Skills, and Abilities:
- Technical knowledge of workers' compensation statutory regulations and medical terminology.
- Strong analytical skills.
- Excellent written and verbal communication skills, including the ability to convey technical details to claimants, attorneys, providers, and internal stakeholders.
- Ability to interact effectively with individuals at all levels of the business environment.
- Ability to independently and effectively manage very complex workers’ compensation claims.
- Proficient in Microsoft Word and Excel (preferred).
Other Qualifications:
- Certifications and/or licenses as required by state regulations.
- California Self-Insurance Plans (SIP) Certification required.
Pay: $90,000.00 - $100,000.00 per year Status: Full-Time / Direct Hire Location: Remote (Must Live in California) Pay: $90,000.00 - $100,000.00 per year Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Referral program
- Vision insurance
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