Medical Claims Examiner

$57,616 - $61,235/Yr

System 1 Staffing

Full-time - Mid Level

Remote

About the position

The Medical Only Claims Examiner will support the Workers Compensation department by adjusting workers' compensation medical claims, ensuring timely processing of claims and payment of benefits, and managing medical treatment. This role is essential for maintaining effective communication with employers, employees, and medical professionals while ensuring compliance with relevant regulations and policies.

Responsibilities

• Review daily diary for claim status
• Review medical reports to determine whether additional medical opinions are needed
• Object to unauthorized medical treatment
• Establish contact with employer to review issues
• Respond to inquiries from the employer, employee, doctors, and attorneys
• Establish and maintain appropriate reserves
• Evaluate and approve medical procedures and treatment
• Review medical bills for appropriateness
• Discuss appropriateness of medical treatment with medical case manager
• Prepare and present reports to clients
• Close claims appropriately
• Help resolve client billing and payment inquiries
• Investigate complaints from injured workers
• Document and code the claim files and claims system with all relevant information
• Maintain and update action plans within specified time frames
• Provide customer service and support to clients and claimants

Requirements

• High School Diploma or equivalent (GED) required
• Administrators Certificate from Self-Insurance Plans required within one year of employment if not already obtained
• Current Experienced Indemnity Claims Adjuster Designation as defined in California Code of Regulations
• Proficiency in determining case value and negotiating settlements
• Understanding of medical and legal terminology
• Completion of Insurance Education Association (IEA) or equivalent training
• Designation with current continuing education hours
• Knowledge of workers' compensation case law, policies, and procedures
• Knowledge of claims handling procedures
• Mathematical calculating skills
• Well-developed verbal and written communication skills with strong attention to detail
• Excellent organizational skills and ability to multi-task
• Ability to type quickly, accurately and for prolonged periods
• Proficient in Microsoft Office Suite
• Ability to learn additional computer programs
• Reasoning ability, including problem-solving and analytical skills
• Ability to be trustworthy, dependable, and team-oriented

Nice-to-haves

• Experience in a remote work environment
• Familiarity with additional claims management software

Benefits

• Competitive hourly pay
• Remote work flexibility
• Opportunities for professional development and training