CLAIMS EXAMINER III (HYBRID)

Concord, CA | Hybrid (3 Days Onsite / 2 Days Remote)

Salary Range: $95,000 - $100,000 + Full Benefits

Level Experienced | Position Type Full Time | Job Shift Day | Category Insurance

MUST have experience handling complex and litigated Workers’ Compensation claims

SIP Certification Required

Here are some of the benefits you can enjoy in this role:

• Medical, Dental, Vision Insurance

• Life and Disability Insurance

• 401(k) Plan

• Paid Holidays

• Paid Time Off

• Referral Bonus

POSITION SUMMARY:

Under minimal supervision, investigates, evaluates, manages, and resolves moderately complex to complex/high-exposure Workers’ Compensation claims. Responsible for determining coverage, compensability, liability, reserve adequacy, and overall claim strategy while ensuring compliance with applicable statutory and regulatory requirements.

This position requires regular interaction with injured workers, employers, attorneys, medical providers, vendors, and internal stakeholders to drive timely and cost-effective claim resolution.

DUTIES AND RESPONSIBILITIES:

• Independently manages moderately complex to complex/high-exposure Workers’ Compensation claims from inception through closure.*

• Investigates claims and determines coverage, compensability, and appropriate claim handling strategy.*

• Analyzes claim exposure and develops action plans to mitigate risk and achieve timely claim resolution.*

• Establishes and maintains accurate reserves throughout the life of the claim.*

• Coordinates medical treatment and manages all medical aspects of claim files with a focus on return-to-work outcomes.*

• Facilitates temporary, transitional, modified, and alternate duty return-to-work programs.*

• Communicates with injured workers, employers, medical providers, attorneys, and vendors regarding claim status and resolution.*

• Refers files to approved vendors for medical management, investigations, conditional payments, and other specialized services as appropriate.*

• Identifies and pursues subrogation opportunities and reimbursement recoveries.*

• Maintains compliance with Medicare reporting requirements and carrier excess reporting thresholds.*

• Manages litigated claims and works closely with defense counsel to develop strategy and drive favorable outcomes.*

• Reviews ongoing claim activity and clearly communicates action plans and recommendations.*

• Maintains accurate documentation and claim activity within the claims management system.*

• Controls claim-related expenses and ensures efficient utilization of resources.*

• Participates in client claim reviews and discusses ongoing claim strategies and outcomes.*

• Mentors and provides guidance to junior Workers’ Compensation Examiners.*

• Performs other duties as assigned.*

*Essential job function.

EQUIPMENT OPERATED/USED:

Computer, fax machine, copier, printer, and other standard office equipment.

SPECIAL EQUIPMENT OR CLOTHING:

Appropriate office attire.

QUALIFICATIONS:

Education/Experience:

• High School Diploma or GED required.
• Bachelor’s degree in a related field strongly preferred, or an equivalent combination of education and experience.
• Three (3) to five (5) years of Workers’ Compensation claims administration experience handling self-insured and/or insured claims.

Knowledge, Skills, and Abilities:

• Experience handling complex, high-exposure, and litigated Workers’ Compensation claims.

• Strong understanding of claim strategy, compensability analysis, reserving practices, and claim mitigation techniques.

• Knowledge of Workers’ Compensation regulations, medical terminology, and claims administration processes.

• Strong analytical, critical thinking, and problem-solving abilities.

• Excellent verbal and written communication skills.

• Strong negotiation, planning, and organizational skills.

• Ability to manage multiple priorities in a fast-paced environment.

• Proficiency with Microsoft Office applications and claims management systems.

• Ability to work independently while maintaining strong collaboration with internal and external stakeholders.

• Demonstrated attention to detail and sound decision-making skills.

Preferred Qualifications:

• Multi-jurisdiction Workers’ Compensation experience.

• Appropriate state licenses and/or certifications as required.

• Bilingual Spanish language skills.

• SIP Certification.

If you're an experienced Workers’ Compensation professional looking for the opportunity to handle complex claims, work within a collaborative team environment, and advance your career with a growing organization, we'd love to connect.