Senior Claims Examiner - Workers Compensation
Athens Administrators - Concord, CA

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Job Summary:

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.

Principal Duties and Responsibilities:
Incumbent must have the skills, ability and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation:

  • 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
  • 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, rehabilitation plans, 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 Claims Assistants and assist with training, coaching, and mentoring as needed for them to support daily claims tasks
  • Provide indirect supervision to Assistant Claim Examiners, Data Entry Clerks and Mail Clerks
  • 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
  • Authorize and negotiate cost of medical treatment and supplies
  • Internal communication with staff

Essential Job Requirements:
The requirements listed below are representative of the knowledge, skill, and/or ability required.

  • High School diploma
  • Administrators Certificate from Self-Insurance Plans
  • Completion of IEA or equivalent courses
  • Must possess a current Experienced Indemnity Claims Adjuster Designation, provided by an insurer, as defined in California Code of Regulations, Title 10, Chapter 5, Subchapter 3, Section 2592.01(f)
  • Solid knowledge of workers’ compensation laws, policies and procedures
  • Proficiency in determining case value and negotiating settlements
  • Understanding of medical and legal terminology
  • Strong verbal and written communication skills
  • Negotiating skills
  • Mathematical calculating skills
  • Computer processing skills
  • Able to operate standard office equipment
  • Ability to work in a paperless environment
  • Valid Drivers license and availability for travel
  • Working knowledge of related information systems, including:

o Microsoft Office (Word and Outlook)


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