Claims Examiner - Claims Specialist

Job Summary

The Claims Examiner, under direct supervision of the Claims Assistant Manager or Claims Manager, will handle lost time claims with a close period of indemnity benefits and non-complex medical injuries.   Works on problems of limited to moderate scope where analysis of situations or data requires a review of a variety of factors. Exercises judgment within defined procedures and practices to determine appropriate action. Duties include: Review of claims to determine compensability, review of medical documentation, establishment of reserves, maintain diary within Best Practice Standards.  The Claims Examiner will communicate with insureds, claimants and medical providers.  The Claims Examiner will ensure that state claims handling requirements are met as well as compliance with our Claims Best Practices. The Claims Examiner is expected to learn and become proficient in the handling of workers’ compensation claims with limited to moderate period of disability. 

Duties and Responsibilities

• Continuously exhibit and uphold Core Values of Integrity, Accountability, Communication and Teamwork, Innovation and Customer Service.
• Conduct three point contacts
• Determine compensability
• Issue workers’ compensation benefits
• Develop plans of action to resolution, coordinate return to work efforts and approved medical payments.
• Investigates Subrogation and negotiate limited settlements within authority level.
• Maintains contact with policyholders and injured workers.
• Ensure claims files are appropriately documented.
• Completes and files appropriate FROI and SROI’s as required by individual State Workers’ Compensation Statute and EDI reporting regulations.
• Manages claims in accordance with Falls Lake Best Practices
• Employs appropriate claims management techniques and direct intervention (referrals for nurse case management, independent medical examinations, utilization review) to manage each claim.
• Makes decisions within delegated authority.
• Have a general understanding of all legislative requirements and is able to take direction to meet those requirements in a prudent business manner.
• Maintains a license for all states and products serviced as required.
• Organize and update all reference material to reflect current legislation and regulatory compliance.
• Comply with all quality control standards set by the company for the handling of claims. Comply with all procedures set forth by the company for performing the job as it relates to the various components of claim administrative services.
• Immediately notify Management of any unusual lawyer inquiries, insurance carrier inquiries, or department of insurance inquiries.

Knowledge, Skills and Abilities

• Familiar with the claims handling process
• Knowledge of medical terminology
• Customer Service focused
• Organizational skills
• Time Management skills
• Excellent oral and written communication skills
• Attention to detail
• Strong Computer Skills
• Hands on Learner
• Ability to multi-task
• Team Attitude
• Ability to successfully obtain the required state adjusters’ licenses within six (6) months following the completion of Company-provided licensure training courses and maintain appropriate licensure thereafter.

Experience and Education

Claims Examiner

• Four-year college degree preferred
• One to three years of claims handling experience
• Experience in working with liability and coverage issues
• Experience negotiating settlements with claimants and attorneys
• Multi-jurisdictional claims experience preferred, may be required depending on type of claim
• Adjuster license and/or certifications preferred

Senior Claims Examiner

• Four-year degree preferred
• Five plus years of claims handling experience  
• Experience and proven track record in managing complex coverage issues and complex litigation
• Multi-jurisdictional claims experience
• Adjuster license and/or certifications desired but not required

Claims Specialist

• High school diploma required
• Bachelor’s Degree preferred
• Advanced Degree or Juris Doctorate Degree preferred
• Minimum of seven years of P&C claims handling experience including working with complex coverage issues, handling liability and coverage issues, multi-jurisdictional claims, and negotiating settlements with claimants and attorneys required
• Adjuster license and/or certifications desired preferred