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Workers' Compensation Sr. Claims Examiner


Listing Summary

General Definition of Work

Performs difficult skilled technical work managing and resolving assigned property and liability and/or assigned lost time and complex medical only claims to ensure prompt determination of compensability, payment of entitled benefits, litigation management and effective claim resolution based on the facts of the claim, and related work as apparent or assigned.  Work is performed under the limited supervision of the Claims Supervisor.

This position will be performed in a telecommuting work environment within the state of Georgia. The employee’s telecommuting work site location will contain a designated and approved work space at the employee’s home address.

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential function satisfactorily.  The requirements listed below are representative of the knowledge, skill and/or ability required.  Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.

Position Responsibilities

Claims Investigation and Administration

  • Initiates initial investigation for newly assigned insurance claims; confirms coverage of claim, contacts member, member representative, non-represented claimants, claimant’s attorney and/or injured employees to obtain/provide information.
  • Initiates compensability and/or liability determination through completion of statements, recorded statements, on-site investigations, and evaluation of property damage appraisal reports.
  • Sets initial reserves for claims; performs proper and timely reserve evaluations and adjustments; reviews and approves bills for processing; reviews medical/rehabilitation notes; reviews and signs off daily check sheet; prepares and submits reports to excess carriers when loss is greater than one-half retention level.
  • Establishes and maintains proper claim diary requirements of existing caseloads with documentation of action plans; ensures action plans are adhered to in a timely manner.
  • Receives and responds to inquiries and requests for information from members, injured employees, vendors, case managers, legal representatives and medical providers.
  • Completes Electronic Data Interchange (EDI) transmissions, state board filings and completes Centers for Medicare Services (CMS) requirements.
  • Utilizes cost control measures regarding claims management when applicable including One Call Medical, Align, Cypress Care, Telephonic Case Manager (TCM), Field Case Manager (FCM) and Surveillance; works at eliminating the payment of fines and penalties due to late and/or form filings.
  • Conducts litigation management of all litigated files with approved defense counsel; prepares action plans and budgets of litigated files; attends mediation, arbitration and trials when necessary; reviews and approves defense counsel billings to ensure accuracy.
  • Occasional overnight travel required – less than 20 days per year – i.e. travel to mediations, hearings, field investigations, depositions, account/member visits, and seminars.

Knowledge, Skills and Abilities

  • Thorough knowledge of business English, spelling and arithmetic;
  • Thorough knowledge of standard office practices, procedures, equipment and administrative support techniques;
  • Thorough knowledge of the workers' compensation system requirements and medical only claim administration;
  • Thorough knowledge of the principles, practices and process of liability claims handling and administration;
  • General knowledge of the laws, legal codes, court procedures, precedents, government regulations and agency rules regulating the property and liability and/or workers compensation insurance industries;
  • Thorough knowledge of ACCG organization and Insurance Division programs and policies;
  • Skill in the use of standard office software equipment and applications, specifically Microsoft Office products, including Outlook, Word and Excel;
  • Ability to communicate ideas effectively in both oral and written formats; ability to type accurately at a reasonable rate of speed;
  • Ability to follow oral and written instructions; ability to read and understand detailed and complicated policies, procedures and materials that contain specialized words and phrases;
  • Ability to make arithmetical calculations; ability to operate a variety of standard office equipment including personal computer and associated software;
  • Ability to establish and maintain effective working relationships with associates, claimants, attorneys, Nurse Case Managers, physicians, local government officials, customers and the general public.

Education and Experience

  • Bachelor's degree with coursework in business administration, insurance, or related field and
  • Extensive (6 years or more) progressive, related experience in property liability or workers' compensation claim handling requirements and administration, or
  • Equivalent combination of education and experience.
  • Working conditions with absence of disagreeable conditions and little or no accident or health hazards; considerable mental effort and stress involved which could result in tension or anxiety.

Special Requirements

  • Employee is required to have and maintain a high-speed, broad-band internet connection at their work site that is sufficient to enable fast, consistent service to the membership.
  • Possession of or ability to acquire a Georgia Independent Adjusters License issued through the State of Georgia Insurance Department within one year of employment.
  • Valid driver's license in the State of Georgia.

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