Workers Compensation Sr. Claims Examiner - CCCSIG Contra Costa County Schools Insurance Group

Contra Costa County Schools Insurance Group

Pleasant Hill, CA

Workers’ Compensation Sr. Claims Examiner

The Contra Costa County Schools Insurance Group (CCCSIG) is inviting applications from well-qualified individuals for the position of Workers’ Compensation Sr. Claims Examiner.  The Sr. Claims Examiner performs the most difficult and responsible types of duties assigned to classes within this series utilizing skills that require an understanding of the most complex claims, analytical procedures and processes, while working with a very high level of independent authority and judgement.

AN IDEAL CANDIDATE will be detail-oriented, accurate, organized, a team player and have good time management skills.  An ideal candidate will have experience with CA workers’ compensation, preferably working with education code.

COMPENSATION

The Sr. Claims Examiner salary is a 5-step range, $95,302.86—$115,841.22/yearly. Placement on the salary schedule is dependent upon prior experience.  Additional compensation is provided for benefits through an IRC-125 Cafeteria Plan.

Employees earn 8 hours of vacation per month along with 14 paid holidays.  Full-pay sick leave is also earned at the rate of 8 hours per month. Retirement benefits are provided through the Public Employees Retirement System and  are not coordinated with Social Security.  PERS is an employee/employer contributory plan.

Only those applicants who have followed application procedures will be considered for this position.  Any applicant who attempts to directly contact individuals from the Agency with the intent of influencing the decision will be disqualified from candidacy.  CCCSIG is an EOE. 

RESPONSIBILITIES INCLUDE (but are not limited to):

• Leads, oversees and performs the more complex and difficult work of staff responsible for claims examination within the Claims Department..

• Administers the processing of claims; receives new claims; enters claim information into on-line claims system; sets up and maintains claim files and records.

• Contacts professionals assisting in analyzing and researching claims including member districts, legal counsel, rehabilitation coordinators, medical evaluators and investigators; provides and collects information.

• May provides leadership, direction and training to other members of the Claims Department assigned to the same district, ensuring adherence to policies and procedures established for the Claims Department; proper work methods, techniques and compliance with applicable standards and specifications.

• Takes statements from involved parties in claims including witnesses; educates claimants on the claims process; reviews laws, codes, and governmental regulations relative to Workers’ Compensation claims processing and maintains CCCSIG Best Practices.

• Analyzes medical records, reports and investigations; participates in the determination of claim acceptance or denial.

• Coordinates and analyzes the medical aspects of claim files for the determination of treatment and testing procedures; reviews medical reports to determine level of disability.

• Participates in the authorization of payments to claimants, medical providers and vendors; determines payment due dates of disability and rehabilitation claims; issues checks and benefit payments.

• Assesses the potential cost of claims; monitors assigned claims throughout the process.

• Negotiates settlements with claimants and attorneys for claims determination; denies claims as appropriate.

• Assigns and prepares files for litigation proceedings; maintains files with on-going litigation documents and claims correspondence; reviews file for closure; prepares proper correspondence for closure; closes out files.

ABILITY TO:

• Perform complex journey level activities in the evaluation and determination of a variety of workers’ compensation claims .

• Organize, develop and prepare claims for assignment to counsel, trial and pre-trial conferences .

• Work independently in the absence of supervision.

• Compile and maintain accurate and complete records and reports.

• Accurately use the computer and the workers’ compensation data based program in the course of work.

• Type (key) at a speed necessary for successful job performance.

• Communicate clearly and concisely, both orally and in writing.

• Establish and maintain effective working relationships with those contacted in the course of work.

KNOWLEDGE OF:

• Principles and procedures of record keeping.

• Basic medical terminology.

• Laws, rules and regulations pertaining to claims adjusting including reserving practices and techniques sufficient to set and maintain responsible levels on all claims, with awareness of excess carrier reporting requirements.

• Computer and usage of workers’ compensation data based systems Basic mathematics.

• Proper English usage, composition, spelling, punctuation and grammar.

EDUCATION/TRAINING & EXPERIENCE GUIDELINES:

Any combination of experience and training that would likely provide the required knowledge and abilities is qualifying.  A typical way to obtain the knowledge and abilities necessary are:

Experience:

• Three years of claims examining experience including claims analysis, working with claimants and professional contacts in the workers’ compensation area, and claims analysis and award determination.

Training:

• Equivalent to completion of twelfth grade supplemented by specialized training in claims adjustment. A Bachelor’s degree in business administration, public administration or a related field is desirable.  Must complete 30 hours of continued education every two years related to CA Workers’ Compensation Administration (ongoing).

Licenses or Certificates Required

• Possession of Self-Insured Administrator’s Certificate issued by the State of California.  Must possess and maintain an Experienced Claims Adjustor Designation.

Resumes can be emailed to

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