Workers Compensation Claims Examiner

The James Allen Companies Inc Published: July 11, 2017
Job Type


General Job Summary:

The Claims Examiner III will manage a caseload of workers’ compensation claims by reviewing new claims to determine the compensability of claims, ascertaining proper filings, identifying the need for further investigations according to our best practices and state regulations. In addition, the Claims Examiner III will work closely with injured workers, insured’s, agents, medical provides as well as defense and claimant attorneys to achieve the best possible outcome for each claim. Settle claims with claimants in accordance with Company policy provisions and State Statute.

Essential Job Functions:

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty.

  • Investigate and handle complicated medical and indemnity
  • Work within established authority on moderate to difficult
  • Work with Supervisor or Claims Analyst as well as defense counsel in managing litigated
  • Communicate daily with employers, physicians, attorneys and injured workers by providing a high level of customer
  • Interpret information and make compensability decisions on more complex files in conjunction with Supervisor or Claims Analyst, when
  • Manage all aspects of investigative activity on claims and develop discovery and direct litigation strategy with assistance of legal counsel pursuant to file handling best
  • Handle all aspects of investigation on moderate to large
  • Analyze claims activity and prepare reports for clients and management, as
  • Establish reserves using independent judgment and expertise and authorizes payments within scope of authority, settling claims in the most cost effective
  • Develop subrogation and third party recovery potential and follow recovery
  • Participate in claim
  • Ensure the administration of all benefits in a timely manner pursuant to state statute or internal best
  • Make decisions regarding the utilization, coordination and management of other resources/specialists (managed care, return to work, etc.) while retaining overall management of the
  • Evaluate and analyze information using good judgment for effective decision making pursuant to claim.
  • Perform excellent claims management by investigating, identifying and following up on critical issues in a timely manner to the point of

Knowledge and Skills required:

  1. Education/Experience
    • Bachelor’s Degree
    • Minimum of 3 years workers’ compensation claims handling experience to include loss time claims is required.
  1. Knowledge and Skills
    • In order to perform the essential functions of this position, an individual must have a thorough understanding of the English language including grammar and
    • Understand the basic principles of mathematics including addition, subtraction, multiplication, division, computation of rate, ratio and
    • Thorough knowledge of workers’ compensation insurance
    • Knowledge of various state workers compensation
    • Thorough knowledge of medical and legal terminology used in processing workers’ compensation claims.
    • Proficient with Microsoft Office as well as basic office machines and
    • Knowledge of or ability to learn iVOS claims

  1. Certifications/Licenses
    • Insurance related professional designation
    • Read, interpret and comprehend memos, letters, general business periodicals, professional journals, medical manuals, computerized drug reference/CPT code manuals and governmental regulations.
    • Solve practical problems and deal with a variety of variables in situations where only limited standardization
    • Interpret a variety of instructions furnished in written, oral, diagram or scheduled
    • Be capable of planning and organizing work, managing multiple priorities, conducting research, making decisions, listening effectively and maintaining self-control and/or composure under
    • Possess good interpersonal and communication
    • Ability to work in a team
    • Effectively manage
    • Pay attention to
    • Be
    • Keyboard at least 30

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