Sr. Workers' Compensation Claims Examiner (Full Remote - TX) (Contract to Perm)
Our Client has an immediate need for a full-time Claims Examiner to support our Workers Compensation department. Multiple levels are being considered for this role. Level and pay range will depend on relevant experience. This role can be worked remotely if technical requirements are met, and the employee resides in Texas. The Claims Examiner will adjust workers compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, setting reserves, and negotiating settlements.
Job Description:
Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:
- Establish contact with employer to review issues
- Respond to inquiries from the employer, employee, doctors, and attorneys
- Establish and maintain appropriate reserves
- Review legal correspondence and medical reports
- Timely referral of treatment plans to Utilization Review to evaluate and approve medical procedures and treatment
- Administer benefits and ensure appropriateness of all payments
- Investigate coverage, liability, and monetary value of claim
- Review medical and legal bills for appropriateness
- Discuss appropriateness of medical treatment with medical case manager
- Determine compensability
- Monitor and assist litigation
- Negotiate settlement of claim, liens, etc.
- Prepare and present reports to clients
- Appropriately close claims
- 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 direction to Assistant Claims Examiners and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks
- Contact with employers, employees, attorneys, doctors, vendors and other parties
- Provide customer service and support to clients and claimants
- Work collaboratively with attorneys to draft settlements and assist with litigation strategies
- Negotiate settlements
- Ensure proper SJDB and DWC notices are sent
- Authorize and negotiate cost of medical treatment and supplies
Team Lead Responsibilities (for Lead Sr. Claims Examiner level only):
Provide support to supervisor with the oversight and claims quality of the Sr. Claims Examiners, Future Medical Claims Examiners, Claims Examiners, and Assistant Claims Examiners.
Position Qualifications:
- High School Diploma or equivalent (GED) required for all positions
- AA/AS or BA/BS preferred but not required
- Texas 03 WC or Texas 8 All Lines license required within one year (Claims Examiner I and II)
- OR
- The Texas 03 Workers’ Compensation license is require, The 08 All Lines License is preferred (Lead Sr. Claims Examiner)
- Workers Compensation training required
- 1-3 years workers compensation claims handling experience (Claims Examiner I and II)
- OR
- 3+ years recent workers compensation claims handling experience required; At least 5 years of workers compensation claims experience preferred (Lead Sr. Claims Examiner)
- Completion of Insurance Education Association (IEA) or equivalent courses
- Solid knowledge of workers compensation laws, policies, and procedures
- Proficiency in determining case value and negotiating settlements
- Understanding of medical and legal terminology
- Negotiating skills
- Mathematical calculating skills
- Ability to carefully review records prior to sending to correct parties
- 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, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution
- Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization
- Seeks to include innovative strategies and methods to provide a high level of commitment to service and results
- Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor
Pay Ranges:
Claims I: $31.54-$37.94
Claims II: $34.61-$41.53
Senior: $42.05-$50.25
**JSG offers medical, dental, vision, life insurance options, short-term disability, 401(k), weekly pay, and more. Johnson Service Group (JSG) is an Equal Opportunity Employer. JSG provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, marital status, protected veteran status, or any other characteristic protected by law.
