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Claims Examiner - Workers Compensation

Location: Brea
Posted on: May 19, 2023

Job Description:

Job Description:

Pay Range: $45 hr - $50hr


  • 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 clams 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.


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


      • Bachelor's degree from an accredited college or university preferred.
      • Professional certification as applicable to line of business preferred.

        Skills And Knowledge:

        • 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.

Keywords: CYNET SYSTEMS, Fullerton , Claims Examiner - Workers Compensation, Other , Brea, California

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