Claims Examiner

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.

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