Medical Only Claims Examiner

Company Details

Preferred Employers Insurance, A Berkley Company specializes in providing workers’ compensation insurance to California business owners. The company serves three major Product/Client Segments: Small Business, Mid-Larger Businesses and Group Association Members (Programs). The company’s distribution partners (agents & brokers) number just under 400 locations throughout the state. Preferred serves thousands of policyholders and provides medical claims handling and claims management as needed to care for injured workers. The company is rated A Superior by industry-rating organization, AM Best & Company.

Responsibilities

The Medical Only Claims Examiner is the first professional level of claim administration. This level examiner is closely supervised, has a general understanding of department objectives and is sufficiently knowledgeable in workers’ compensation laws to administer medical claims benefits.  This position will determine compensability of medical only cases and process bills for payment by reviewing Explanation of Reviews (EORs) on closed, as well as open claims. Medical only claims primarily consist of non-litigated, no lost time, soft tissue type injuries, including strains/sprains.  In addition, this position will also back up the First Report Unit and Claims Assistant ACD phone group. Claims handling activities will be performed in compliance with the rules, regulations and statutes of the WCAB and the State of California.

Key functions include, but are not limited to the following:

• Provide customer service – answer telephones by the third ring and re-direct callers as necessary to properly respond to customer inquiries.
• Complete three-point contact to properly investigate assigned claims, evaluate coverage and determine compensability.
• Perform data entry to setup new claims, work diaries and create activity notes.
• Complete and prepare documentation for referrals to investigators and copy service subpoenas.
• Manage initial and subsequent treatment within the Medical Provider Network.
• Assist in the delivery of medical care in accordance with MTUS guidelines and Utilization Review.
• Reserve claim files appropriately for anticipated expense and medical costs.
• Complete assigned work via diaries and work queues in a timely manner.
• Perform other duties as requested by manager.

Qualifications

• 4-year degree or knowledge of workers’ compensation principles and policies equivalent preferred.
• Must meet California certification requirements for Medical Only Examiner.
• Strong written and verbal communication skills, attention to detail and deadline structures.
• Ability to work both independently and collaboratively with all levels of staff.
• Proficient with MS Office software and PC applications and systems.

Additional Company Details

Additional Requirements