Senior Claims Examiner

Full Job Details:

Athens Administrators has an immediate need for a full-time Senior Claims Examiner to support our workers compensation department. Employees who live less than 26 miles from the San Antonio, TX office are required to work once a week in the office on a day determined by their supervisor between Tuesday – Thursday. The remaining days can be worked remotely if technical requirements are met, and the employee resides in Texas.

Athens offices are open for business Monday-Friday from 7:30 a.m. to 5:30 p.m. local time. The schedule for this position is Monday-Friday at 37.5 hours a week with the option of a flex schedule. The Senior Claims Examiner will adjust workers’ compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, setting reserves, and negotiating settlements.

Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:

• Process new claims in compliance with client’s Service Agreement
• Establish contact with employer to review issues
• Respond to inquiries from the employer, employee, doctors, and attorneys
• Establish and maintain appropriate reserves
• Review legal correspondence and medical reports
• Evaluate and approve medical procedures and treatment
• Administer benefits and ensure appropriateness of all payments
• Investigate coverage, liability, and monetary value of claim
• Review medical and legal bills for appropriateness
• Discuss appropriateness of medical treatment with medical case manager
• Monitor and assist litigation
• Negotiate settlement of claim, liens, rehabilitation plans, etc.
• Prepare and present reports to clients
• Appropriately close claims
• Help resolve client billing and payment inquiries
• Investigate complaints from injured workers
• Document and code the claim files and claims system with all relevant information
• Maintain and update action plans within specified time frames
• Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks
• Contact with employers, employees, attorneys, doctors, vendors and other parties
• Provide customer service and support to clients and claimants
• Work collaboratively with attorneys to draft settlements and assist with litigation strategies
• Negotiate settlements
• Authorize and negotiate cost of medical treatment and supplies
• Internal communication with staff
• Prepare professional, well written correspondence and other communications

The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.

• High School Diploma or equivalent (GED) required for all positions
• AA/AS or BA/BS preferred but not required
• The Texas 03 Workers’ Compensation license is required
• The 08 All Lines License is preferred
• 3+ years recent workers compensation claims handling experience required
• At least 5 years of workers compensation claims experience preferred
• Solid knowledge of workers compensation laws, policies, and procedures’
• Completion of IEA or equivalent courses
• Proficiency in determining case value and negotiating settlements