Workers Compensation Claims Examiner

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• Be Present
• Have Fun

The Workers' Compensation Claims Examiner is responsible for managing an inventory of high-exposure, complex, and litigated Workers' Compensation claims for DecisionHR PEO clients, ensuring each claim is thoroughly investigated, properly reserved, and driven to the most cost-effective and timely resolution. This role serves as the primary claims contact for assigned client companies and injured employees, partnering closely with carriers, third-party administrators, adjusters, defense counsel, medical providers, and loss control representatives throughout the life of each claim.

The Claims Examiner operates with a high degree of independence and accountability, combining technical claims expertise with proactive client communication, risk mitigation strategy, and return-to-work program coordination. This is an individual contributor role reporting to the Workers' Compensation Claims Manager.

• Serve as the primary intake point for first reports of injury from client companies and injured employees; conduct employer-level investigations and process insurance claims to the carrier or TPA for handling in a timely and accurate manner.
• Interview claimants, witnesses, and client representatives to gather all pertinent information needed to support a complete and accurate claim investigation.
• Verify coverage applicability through the applicable insurance policy; confirm that the injury, incident, and parties are covered under the policy terms before proceeding with claim processing.
• Evaluate claimant remuneration to determine appropriate compensation amounts; prepare and submit wage statements to the carrier for calculation of average weekly wage and applicable benefits.

• Manage an active inventory of high-exposure, complex, and litigated Workers' Compensation claims from intake through resolution, ensuring each claim is properly investigated, reserved, and driven toward the most advantageous and cost-effective outcome.
• Collaborate closely with carrier adjusters to ensure sound claim decisions, accurate reserve levels, financial accuracy, subrogation and recovery opportunities, appropriate medical management, and effective litigation management and action planning.
• Complete settlement evaluations for assigned claims; work with the adjuster and defense counsel to develop and execute negotiation strategies that achieve timely and cost-effective resolution.
• Coordinate assignment of telephonic or field nurse case managers and, where warranted, activity checks or surveillance, in coordination with the adjuster throughout the course of a claim.

• Coordinate and actively support the Return to Work program for assigned claims; work collaboratively with client companies, carriers, and medical providers to facilitate the earliest practical return to work for injured employees, reducing compensation costs and minimizing litigation potential.
• Work with Loss Control representatives to facilitate on-site investigation of large losses and emerging risk trends; conduct or coordinate on-site visits promptly following significant loss events, including visits with the injured employee where appropriate.
• Facilitate identification of potential fraud on assigned claims; develop and implement claim strategies that mitigate the organization's exposure to fraudulent filings, coordinating with the adjuster and outside resources as needed.

• Maintain consistent, proactive, and professional communication with assigned client companies throughout the life of each claim; provide timely updates at key claim development milestones and material changes until the claim is closed.
• Consult with clients and employees to obtain information required to complete investigations, support claim decisions, and facilitate timely claim filing and management.
• Assist client companies in developing a thorough understanding of the Workers' Compensation claims process, their obligations and responsibilities, and strategies to reduce future exposure and improve return-to-work outcomes.
• Assist clients in implementing risk reduction strategies based on loss experience trends, claim patterns, and loss control observations.

• Participate in monthly loss experience monitoring with the WC Claims Manager; identify clients with poor or deteriorating loss experience and support the development of targeted loss prevention activity or relationship review recommendations.
• Provide monthly updates on all outstanding indemnity claims to the WC Claims Manager, including status, reserve accuracy, anticipated resolution timeline, and any material developments.
• Prepare and maintain accurate claim documentation, notes, and activity logs in the claims management system throughout the life of each claim.