Claims Examiner

About This Role

This role involves managing and reviewing workers' compensation claims as a Claims Examiner. The core of the job is investigating and processing insurance claims, negotiating settlements, and maintaining accurate claims records. It suits a detail-oriented, proactive, and critical thinker with a strong understanding of workers' compensation policies and regulations.

Responsibilities

• Analyze and process complex claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim
• Investigate and evaluate workers’ compensation claims to determine coverage, compensability, liability, and benefits owed
• Conduct detailed reviews of medical records, employment records, and other documentation to assess claims
• Handle claim settlements, reviews, and negotiations in a fair and ethical manner
• Communicate effectively with injured employees, employers, medical providers, attorneys, and internal stakeholders to ensure the timely resolution of claims
• Authorize treatment and payments within designated authority levels while ensuring compliance with organization’s policies and applicable state laws
• Prepare and deliver reports documenting claim activity, reserve adequacy, and resolution strategies
• Evaluate ongoing medical treatment plans and facilitate return-to-work options when feasible
• Collaborate with legal teams as needed to support litigation and dispute resolution efforts
• Maintain accurate and up-to-date claim records in accordance with organizational policies and compliance requirements
• Ensure compliance with Department of Labor Federal Employees Compensation Action laws, regulations, and internal policies, meeting deadlines
• Oversee case development, including medical examinations and specialty referrals, to resolve conflicts
• Balance competing priorities in a limited-staff environment while meeting goals for timeliness, accuracy, customer service, and compliance
• Perform other related duties as assigned

Requirements

• Bachelor’s degree with 3+ years or equivalent combination of education and 5+ years of relevant experience
• Demonstrated ability to work independently and collaboratively in a team environment
• Excellent written and verbal communication skills
• Strong organizational skills with exceptional attention to detail
• Strong negotiation and problem-solving skills
• Proven ability to handle and maintain the confidentiality of sensitive information and materials
• Extensive customer service experience with a strong focus on professionalism and responsiveness
• Proficiency in Microsoft Office Suite or similar productivity software