Workers Compensation Claims Examiner II

POSITION SUMMARY:

Under general supervision and within established Company policies, procedures, claim handling standards, and applicable state regulations, assists in the administration and processing of workers’ compensation indemnity claims from inception to conclusion.

This position performs claims handling activities in accordance with established workflows, supervisory direction, and designated authority guidelines. The Claims Examiner II regularly communicates with claimants, clients, medical providers, vendors, legal counsel, and internal staff regarding claim status, documentation, treatment coordination, and benefit administration.

The position is classified as hourly non-exempt and is eligible for overtime compensation in accordance with applicable federal and California wage and hour laws. Employees are expected to accurately record all hours worked and obtain approval for overtime work consistent with Company policy.

DUTIES AND RESPONSIBILITIES:

Manages a workers’ compensation caseload generally ranging from approximately 110–130 files, depending on claim complexity, staffing levels, and operational needs.

Reviews new claim assignments and completes timely initial claim setup and investigation activities following Company procedures and supervisory guidance.

Gathers and documents claim-related information from claimants, employers, medical providers, and other parties.

Applies established Company guidelines and applicable state regulations in the administration of indemnity and medical benefits.

Coordinates medical treatment and reviews medical billing for processing and authorization within assigned authority levels and Company procedures.

Maintains timely and accurate claim file documentation reflecting current claim status and activities performed.

Utilizes the Company diary system to monitor claim activity and follow-up tasks.

Communicates professionally with claimants, employers, medical providers, attorneys, vendors, and clients regarding routine claim matters and claim status updates.

Prepares reserve recommendations and submits reserve changes for review and approval in accordance with Company guidelines and assigned authority levels.

Escalates complex issues, coverage concerns, litigation matters, settlement recommendations, or questions outside assigned authority to supervisory staff.

Participates in file reviews, team meetings, training activities, and operational discussions as requested by management.

Assists in identifying claim trends, return-to-work opportunities, or safety concerns for client communication.

Adheres to Company policies, attendance expectations, confidentiality requirements, and documentation standards.

Performs other related duties as assigned.

Essential job function.

EQUIPMENT OPERATED/USED:
Computer, 10-key, fax machine, copier, printer, and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING:
Appropriate office attire QUALIFICATIONS

REQUIRED:

Education/

Experience:

High school diploma or GED required;
Bachelor’s degree in a related field (preferred); three (3) or more years of related experience; or equivalent combination of education and experience.

Knowledge, Skills, and Abilities:

Technical knowledge of statutory regulations and medical terminology.

Analytical skills.

Excellent written and verbal communication skills, including conveying technical details to claimants, clients, and staff.

Ability to interact with persons at all levels in the business environment.

Ability to independently and effectively manage fairly complex claims.

Proficient in Word and Excel (preferred).Other

Qualifications:

None Mental and

Physical Requirements:

[see separate attachment for a copy of checklist of mental and physical requirements]MENTAL AND

PHYSICAL REQUIREMENTS
1. MENTAL EFFORTa. Reasoning development::

Follow one- or two-step instructions; routine, repetitive task.

Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

X Solve practical problems; variety of variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve…