Workers' Compensation Claims Examiner

Corporate Staffing Solutions, Inc.:

CSSI is a specialized recruiting and consulting firm servicing Third Party Administrators, and the Insurance Industry. We service TPAs, self-insured companies, and more, in the Worker's Compensation field, as well as other industries. We are currently interviewing for a full time position for our client located in the Los Angeles, CA area.

 

Position Description
Administers workers' compensation, sickness and LTD and integrates the delivery of benefits associated with litigated workers' compensation cases with complex issues and non-litigated cases with complex issues.
 
Interprets and applies law to administer workers' compensation claims in compliance with all rules, regulations and reporting requirements of the Labor Code, Division of Workers' Compensation, Self-Insurance Regulations,OSHA, and other administrative laws.
Integrates and administers the delivery of long term disability, sickness allowance, pregnancy-illness benefits and other company/state requirements such as FMLA with workers' compensation benefits.
Reviews and approves benefits payable to injured employee, invoices including attorney bills, medical provider bills, liens and mileage.
Rates employee's permanent disability. Reviews and monitors employee medical records to ensure scope and duration of treatment are appropriate based on the injury and diagnosis.
Seeks recovery from third parties.
Reports appropriate cases to excess insurance and seeks reimbursement.
Manages litigated cases and non-litigated cases with complex issues.
Focuses on cost effective delivery of benefits and resolution of cases.
Develops and documents plan to resolve cases.

 Assigns and directs defense counsel.
Analyzes cases for settlement including need for strutured settlement, medicare set aside and settlement of other cases pending with the company. 
Settles case within authority and recommends settlements to Case Mgmt. Supervisor/Manager.
Evaluates and determines the appropriate individual case reserve of assigned cases for future financial liability.
Identifies and investigates questionable cases, third party, fraud and abuse.
Coordinates vocational rehabilitation, reasonable accommodation requests, company RTW programs and work hardening.
Acts as an information resource to employees, supervisors, doctors, payroll staff, various human resource department and insured programs for WC and LTD.
Promotes litigation avoidance through close contact with employees to assure understanding of claims process, benefits integration, and directs employees to resources that will aid in their return-to-work.
Provides training to Region personnel.
Visits local bases to discuss case strategy with local management.
Fosters a team approach with Field Supervisor for delivery of benefits.
Support peers to ensure high level of customer service to clients.
Participates and testifies in grievances, arbitration and WCAB hearings as required.
Acts as company witness at WCAB hearing on company LTD and sickness issues.
Educates and counsels on complex and sensitive issues

 

Position Qualifications
Self-Insurance Certificate is required, current and on-going education in WC/disability claims administration. Typically requires a minimum of 2 years workers' compensation or disability management experience. Litigated experience is required.
 
Must effectively communicate, both verbally and written, with employees, supervisors and external providers. 
Strong client focus with diplomacy and clear explanation of decisions.
Basic mathematical skills required for calculations and ratings.
Must be well-organized to meet heavy workload and be able to effectively manage multiple demands.
Must have strong teamwork skills.
Knowledge and understanding of workers' compensation claims administration required.
Thorough knowledge of DMS policies and procedures as they relate to the integration of workers' compensation with sickness and long- term disability benefits.
 Good working knowledge of the Union agreement.
 Knowledge of computer applications is required.
Must have thorough knowledge of Self-Insurance regulations, Case Law, Labor Code and rules and regulations of OSHA.
 

Benefits

Medical: HMO/PPOs

Dental: HMO/DMO

Vision: VSP

401k

 

TO APPLY:

Please fax or e-mail resume in MSWord format stating current salary and salary requirements to: (714) 648-0796 or e-mail to: barbara.burke@cssistaffing.com