Claims Examiner - Workers Compensation

Overview

To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.

• Analyze and process complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manage claims through well-developed action plans to an appropriate and timely resolution.
• Negotiate settlement of claims within designated authority.
• Calculate and assign timely and appropriate reserves to claims; manage reserve adequacy throughout the life of the claim.
• Calculate and pay benefits due; approve and make timely claim payments and adjustments; and settle claims within designated authority level.
• Prepare necessary state filings within statutory limits.
• Manage the litigation process; ensure timely and cost effective claims resolution.
• Coordinate vendor referrals for additional investigation and/or litigation management.
• Use appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
• Manage claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
• Report claims to the excess carrier; respond to requests of directions in a professional and timely manner.
• Communicate claim activity and processing with the claimant and the client; maintain professional client relationships.
• Ensure claim files are properly documented and claims coding is correct.
• Refer cases as appropriate to supervisor and management.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travels as required.

• Bachelor's degree from an accredited college or university preferred.
• Professional certification as applicable to line of business preferred.
• Five (5) years of claims management experience or equivalent combination of education and experience required.
• 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.
• Candidate with prior/current CA Indemnity and Litigated Workers Compensation experience is required.
• Self-Insured Plans certification.

Synectics Inc. will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if Synectics Inc. is concerned about conviction that is directly related to the job, you will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.

Find out more about the Fair Chance Act by visiting

• Healthcare Insurance: Synectics offers eligible employees and their dependents healthcare coverage through Blue Cross Blue Shield of Illinois. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics. Premiums are subsidized by Synectics.
• Dental Insurance: Synectics offers eligible employees and their dependents a dental plan through Met Life. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics.
• Vi…