Major Claims Examiner
ICW Group
full-time
Posted on:
Location Type: Hybrid
Location: Sacramento • California • United States
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Salary
💰 $90,559 - $152,723 per year
About the role
- Investigates and gathers necessary information to resolve assigned claims.
- Examines major and catastrophic claims to determine coverage, liability, and damages.
- Communicates with insureds to obtain information necessary for processing claims.
- Partners with legal counsel on litigation strategies while maintaining file ownership.
- Attends depositions and conferences exercising appropriate prioritization based on workload.
- Contacts and/or interview claimants, doctors, medical specialists, or employers to obtain relevant information.
- Conducts thorough investigations, including reviewing medical records, legal documents, and other supporting evidence.
- Directs additional investigation of questionable claims to determine compensability.
- Identifies potential fraud indicators and escalates as necessary.
- Applies technical knowledge and human relations skills to ensure fair and prompt management of cases.
- Manages and approves benefit payments within authority limits, ensuring compliance with state regulations and internal standards.
- Effectively communicates exposure and strategies to senior leadership.
- Resolves claims fairly and equitably, acting in the best interest of the insured and providing benefits as prescribed by law and in accordance with company standards.
- Utilizes structured settlements to resolve high exposure claims.
- Serves as a mentor and works closely with branch staff to devise strategy for reserving and settlement on high exposure claims, as requested.
- Identifies opportunities to engage with other company departments including managed care, legal, payment recovery, and SIU.
- Attends settlement mediations and conferences, as necessary.
- Participates in claim reviews and service calls with insureds and prospective insureds.
- Reduces and mitigates Company’s financial exposure.
- Researches historical billing data for facilities and providers to establish accurate file reserves.
- Analyzes and reports catastrophic and major claims loss data to WCC leaders.
- Implements proactive and strategic plans to bring claims to a timely and appropriate resolution.
- Anticipates future developments and exposures and maintains accurate reserves.
- Pursues subrogation in most cases; refers and/or follows up on subrogation efforts.
Requirements
- Bachelor's degree in Business Administration, Management, Economics, Accounting, or related field (or equivalent combination of work experience and education)
- Minimum 10+ years’ workers’ compensation claims experience with specific experience managing and resolving major claims losses.
- Required to receive certification that meets the minimum standards of training, experience and skill
- Maintain state Workers’ Compensation License, as required
- Continuing education designations (CPCU, AIC, etc.) or other industry licensing and training programs are preferred.
- Expert knowledge of complex claims principles and practices
- Proficiency in claims handling systems, analytics tools, and databases
- Strong understanding of multi-jurisdictional laws
- Ability to apply technical knowledge and human relations skills to ensure fair and prompt management of cases
- Skilled in negotiation, strategic decision-making, and mentoring
- Advanced critical thinking skills and attention to detail
- Excellent verbal and written communication skills, time management, and organizational skills required.
Benefits
- Health insurance
- 401K retirement plans with company match
- Bonus potential for all positions
- Paid Time Off
- Paid holidays throughout the calendar year
- Support for continued learning
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
claims handlinginvestigationnegotiationsubrogationdata analysisstrategic decision-makingclaims loss managementcompliancereservingstructured settlements
Soft skills
communicationmentoringcritical thinkingattention to detailtime managementorganizational skillshuman relationsprioritizationstrategic planningproblem-solving
Certifications
Workers’ Compensation LicenseCPCUAIC