Cynet systems Inc
Claims Examiner - Workers Compensation
Cynet systems Inc, Orange, California, United States, 92613
Job Description
Pay Range: $42.14/hr - $47.14/hr
The Workers’ Compensation Claims Specialist is responsible for managing complex claims from investigation through resolution, ensuring timely and accurate processing, compliance with regulations, and effective cost management. The role includes coordinating with internal teams, vendors, and clients while maintaining professional relationships and thorough documentation.
Responsibilities
Analyze and process complex workers’ compensation claims, gathering information to determine claim exposure.
Manage claims with well-developed action plans to achieve timely and appropriate resolution.
Negotiate claim settlements within designated authority.
Calculate and assign timely and appropriate reserves, monitoring adequacy throughout the claim lifecycle.
Calculate and pay benefits, approve claim payments and adjustments, and settle claims within designated authority levels.
Prepare required state filings within statutory limits.
Manage the litigation process to ensure timely and cost-effective claim resolution.
Coordinate vendor referrals for additional investigation or litigation management.
Apply cost containment strategies, including vendor partnerships, to reduce claim costs.
Manage claim recoveries, including subrogation, Second Injury Fund, and Social Security/Medicare offsets.
Report claims to excess carriers and respond professionally to inquiries.
Communicate claim activity with claimants and clients, maintaining professional relationships.
Ensure proper documentation and correct claims coding.
Refer complex cases to supervisor or management as appropriate.
Perform additional duties as assigned and support organizational quality programs.
Travel as required.
Qualifications Education And Licensing:
Bachelor’s degree preferred.
Professional certification relevant to the line of business preferred.
Experience:
Minimum of 5 years of claims management experience or equivalent combination of education and experience.
Skills And Knowledge:
Expert knowledge of insurance principles, relevant laws, recoveries, offsets, claims and disability duration, cost containment, and Social Security/Medicare procedures.
Excellent oral and written communication, including presentation skills.
Proficiency in Microsoft Office.
Strong analytical and interpretive skills.
Excellent organizational and interpersonal skills.
Strong negotiation skills.
Ability to work effectively in a team environment.
Ability to meet or exceed service expectations.
Work Environment
Mental: Strong judgment, problem-solving, analytical skills, discretion, ability to handle multiple priorities and work-related stress, and meet deadlines.
Physical: Computer keyboarding; travel as required.
Auditory/Visual: Hearing, vision, and speaking.
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The Workers’ Compensation Claims Specialist is responsible for managing complex claims from investigation through resolution, ensuring timely and accurate processing, compliance with regulations, and effective cost management. The role includes coordinating with internal teams, vendors, and clients while maintaining professional relationships and thorough documentation.
Responsibilities
Analyze and process complex workers’ compensation claims, gathering information to determine claim exposure.
Manage claims with well-developed action plans to achieve timely and appropriate resolution.
Negotiate claim settlements within designated authority.
Calculate and assign timely and appropriate reserves, monitoring adequacy throughout the claim lifecycle.
Calculate and pay benefits, approve claim payments and adjustments, and settle claims within designated authority levels.
Prepare required state filings within statutory limits.
Manage the litigation process to ensure timely and cost-effective claim resolution.
Coordinate vendor referrals for additional investigation or litigation management.
Apply cost containment strategies, including vendor partnerships, to reduce claim costs.
Manage claim recoveries, including subrogation, Second Injury Fund, and Social Security/Medicare offsets.
Report claims to excess carriers and respond professionally to inquiries.
Communicate claim activity with claimants and clients, maintaining professional relationships.
Ensure proper documentation and correct claims coding.
Refer complex cases to supervisor or management as appropriate.
Perform additional duties as assigned and support organizational quality programs.
Travel as required.
Qualifications Education And Licensing:
Bachelor’s degree preferred.
Professional certification relevant to the line of business preferred.
Experience:
Minimum of 5 years of claims management experience or equivalent combination of education and experience.
Skills And Knowledge:
Expert knowledge of insurance principles, relevant laws, recoveries, offsets, claims and disability duration, cost containment, and Social Security/Medicare procedures.
Excellent oral and written communication, including presentation skills.
Proficiency in Microsoft Office.
Strong analytical and interpretive skills.
Excellent organizational and interpersonal skills.
Strong negotiation skills.
Ability to work effectively in a team environment.
Ability to meet or exceed service expectations.
Work Environment
Mental: Strong judgment, problem-solving, analytical skills, discretion, ability to handle multiple priorities and work-related stress, and meet deadlines.
Physical: Computer keyboarding; travel as required.
Auditory/Visual: Hearing, vision, and speaking.
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