Title: Claims Examiner
Location: Lake Mary, FL 32746
Duration: Direct Hire
HIRING MANAGER NOTES:
· 5 years of Florida workers’ comp experience or longer
· Person should be licensed in FL
· Heavy Litigation experience
· Should have job stability
· Telecommute is an option however they will have to come onsite for training. Also, the candidate has to be in the state of FL.
PRIMARY PURPOSE:
To analyze complex or technically difficult 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.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
· Analyzes and manages complex or technically difficult 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.
· Assesses liability and resolves claims within evaluation.
· 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 filings 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 be 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.
ADDITIONAL FUNCTIONS AND RESPONSIBILITIES:
· Performs other duties as assigned.
· Supports the organization's quality program(s).
· Travel as required
QUALIFICATIONS:
Education & Licensing:
· Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.
Experience:
· Four (4) years of claims management experience or equivalent combination of education and experience required.