Claims Examiner - Workers Compensation

Primary Purpose:
To analyze complex workers' compensation claims, determine benefits due, and manage high-exposure claims involving litigation and rehabilitation. The role includes ensuring claims adjudication meets service expectations, industry best practices, and specific client requirements, while identifying subrogation opportunities and negotiating settlements.

Essential Functions and Responsibilities:

• Analyze and process complex workers' compensation claims by investigating and gathering necessary information to determine claim exposure.
• Manage claims with well-developed action plans, ensuring timely and appropriate resolution.
• Negotiate settlements within designated authority levels.
• Calculate and assign appropriate reserves to claims, managing reserve adequacy throughout the claim lifecycle.
• Calculate and pay benefits, approving and making timely claim payments and adjustments.
• Prepare necessary state filings within statutory limits.
• Oversee the litigation process to ensure cost-effective claims resolution.
• Coordinate vendor referrals for additional investigation and/or litigation management.
• Utilize cost containment techniques, including strategic vendor partnerships, to reduce overall claim costs.
• Manage claim recoveries, including subrogation, Second Injury Fund recoveries, and Social Security and Medicare offsets.
• Report claims to excess carriers and respond to their requests in a professional and timely manner.
• Communicate claim activity and processing updates with claimants and clients, maintaining professional relationships.
• Ensure proper documentation of claim files and accurate claims coding.
• Refer cases to supervisors and management as appropriate.

Additional Functions and Responsibilities:

• Perform other duties as assigned.
• Support the organization's quality programs.
• Travel as required.

Qualifications:

• Education & Licensing:
  • Bachelor's degree from an accredited college or university preferred.
  • Professional certification relevant to the line of business preferred.
• Experience:
  • Five (5) years of claims management experience or an equivalent combination of education and experience required.
• Skills & Knowledge:
  • Subject matter expertise in insurance principles, laws, recoveries, and cost containment for the line of business handled.
  • Excellent oral and written communication skills, including presentation abilities.
  • Proficiency in Microsoft Office products and general PC literacy.
  • Strong analytical, interpretive, and organizational skills.
  • Good interpersonal and negotiation skills.
  • Ability to work effectively in a team environment and meet or exceed service expectations.

Nesco Resource provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.