Claims Examiner South Portland, ME Administrative Support


Claims Examiner
Location: Portland, ME
Direct Hire
 
Duties:
PRIMARY PURPOSE: To analyze complex or technically difficult claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.
 
ESSENTIAL FUNCTIONS and RESPONSIBILITIES:

Analyzes and manages complex or technically difficult claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
Assesses liability and resolves claims within evaluation.
Negotiates settlement of claims within designated authority.
Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level.
Prepares necessary state filings within statutory limits.
Manages the litigation process; ensures timely and cost effective claims resolution.
Coordinates vendor referrals for additional investigation and/or litigation management.
Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
Manages claim recoveries, including be not limited to subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
Ensures claim files are properly documented and claims coding is correct.
Refers cases as appropriate to supervisor and management.

 
ADDITIONAL FUNCTIONS and RESPONSIBILITIES

Performs other duties as assigned.
Supports the organization's quality program(s).
Travels as required.

 
Skills:   
SKILLS & KNOWLEDGE:

In-depth knowledge of appropriate insurance principles and laws for line of business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedure as applicable to line of business
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Analytical and interpretive skills
Strong organizational skills
Good interpersonal skills
Excellent negotiation skills
Ability to work in a team environment
Ability to meet or exceed Service Expectations

 
EXPERIENCE: Four (4) years of claims management experience or equivalent combination of education and experience required.
 
Education:
Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.
 
To apply for this role, please contact Sedona Staffing by calling 563-556-3040 or email your resume to Darrell@careerpros.com
 
 
Sedona Staffing is an Equal Opportunity Employer
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