Workers Compensation Lost Time Claim Examiner

Sunrise System Inc. is currently looking for

• Job schedule-Hybrid-in office Tues/Wed/Thurs WFH Mon/Fri
• Job hours-8:30-4:30 EST
• Public Transportation available
• Interview process-one

• Handles all aspects of workers’ compensation lost time claims from set-up to case closure ensuring strong customer relations are maintained throughout the process.
• Reviews claim and policy information to provide background for investigation.
• Conducts 3-part ongoing investigations, obtaining facts and taking statements as necessary, with insured, claimant and medical providers.
• Evaluates the facts gathered through the investigation to determine compensability of the claim.
• Informs insureds, claimants and attorneys of claim denials when applicable.
• Prepares reports on investigation, settlements, denials of claims and evaluations of involved parties, etc.
• Timely administration of statutory medical and indemnity benefits throughout the life of the claim.
• Sets reserves within authority limits for medical, indemnity and expenses and recommends reserve changes to Supervisor throughout the life of the claim.
• Reviews the claim status at regular intervals and makes recommendations to Supervisor to discuss problems and remedial actions to resolve them.
• Prepares and submits to Supervisor unusual or possible undesirable exposures when encountered.
• Works with attorneys to manage hearings and litigation
• Controls and directs vendors, nurse case managers, telephonic cases managers and rehabilitation managers on medical management and return to work initiatives.
• Complies with customer service requests including Special Claims Handling procedures, file status notes and claim reviews.
• Files workers’ compensation forms and electronic data with states to ensure compliance with statutory regulations.
• Refers appropriate claims to subrogation and secures necessary information to ensure that recovery opportunities are maximized.
• Works with in-house Technical Assistants, Special Investigators, Nurse
• Consultants, Telephonic Case Managers as well as Team Supervisors to exceed customer's expectations for exceptional claims handling service.

• Lost Time Claim Examiner position with prior experience in workers’ compensation as a medical only examiner, or similar examiner experience in short-term / long-term disability, auto personal injury protection / medical injury, general liability or as a claim technical assistant for lost time claims.
• Requires knowledge of workers’ compensation statutes, regulations and compliance.
• Ability to incorporate data analytics and modeling into daily activities to expedite fair and equitable resolution of claims and claim issues.
• Exceptional customer service and focus.
• Ability to openly collaborate with leadership and peers to accomplish goals.
• Demonstrates a commitment to a career in claims.
• Exceptional time management and multi-tasking capabilities with consistent follow through to meet deadlines.
• Use analytical skills to find mutually beneficial solutions to claim and customer issues.
• Ability to prepare and make exceptional presentations to internal and external customers.
• Conscientious about the quality and professionalism of work product and
• relationships with co-workers and clients.
• Willing to take ownership and tackle obstacles to meet client quality
• standards for service, investigation, reserving, inventory management, teamwork, and diversity appreciation.
• Superior verbal and written communication skills.

• Experience working in a customer focused, fast-paced, fluid environment
• Experience utilizing strong communication and telephonic skills
• Prior experience requiring a high level of organization, follow-up and accountability
• Prior workers’ compensation claim handling experience is a plus but not required
• Familiarity with claim handling (healthcare, short-term / long-term disability, auto personal injury protection / medical injury, or general liability) is a plus but not required
• Prior insurance, legal or corporate business experience is a plus but not required
• AIC, RMA, or CPCU completed coursework or designation(s) is a plus but not required
• Bachelor’s Degree is a plus but not required
• Proficiency with Microsoft Office Products
• Knowledge of medical terminology is a plus but not required
• Knowledge of bill processing is a plus but not required
• Claim Adjuster license in Delaware and West Virginia is required. Adjuster licenses in other states are preferred but not required.