Claims Examiner - Workers Compensation
Company: CYNET SYSTEMS
Posted on: January 17, 2023
- 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
- Analyzes and processes complex or technically difficult
workers' compensation 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
- Negotiates settlement of claims within designated
- Calculates and assigns timely and appropriate reserves to
claims; manages reserve adequacy throughout the life of the
- Calculates and pays benefits due; approves and makes timely
claim payments and adjustments; and settles clams within designated
- Prepares necessary state fillings within statutory
- 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
- Manages claim recoveries, including but 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
- Ensures claim files are properly documented and claims coding
- Refers cases as appropriate to supervisor and management.
- Five (5) years of claims management experience or equivalent
combination of education and experience required.
- Bachelor's degree from an accredited college or university
- Professional certification as applicable to line of business
Skills and Knowledge:
- 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
- Excellent oral and written communication, including
- 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.
Keywords: CYNET SYSTEMS, Concord , Claims Examiner - Workers Compensation, Other , Concord, California
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