worker's compensation claims examiner

Government of the Virgin Islands

JOB
 Under supervision from the section head, an employee in this class investigates claims for loss or damage stemming from injuries obtained by workers; interviews or corresponds with claimants in order to determine the extent of damage and prepares reports of findings and submits such for the settlement of claims. An employee in this position provides support to the program under guidance and supervision of the head of the unit. General supervision is received through conferences and review of work for compliance with departmental rules and regulations.
 
EXAMPLE OF DUTIES
 DUTIES (NOT ALL INCLUSIVE) Provides information to the public, particularly employees and employers on the provision of the Worker's Compensation Chapter relative to insurance coverage, benefits and the requirements for the filing of claims. Receives and examines reports of injury. If damages are evident, invites prospective claimants in for interviews. Assists claimants in preparation of claims. Assists injured workers in obtaining medical and in obtaining medical reports for completion of their claims prior to settlement. Calculates and prepares payments due claimants on claims; prepares and submits orders and voucher for payment of claims for signature by the administrator. Forwards to the Government Insurance Fund, orders and vouchers for payment, and distributes checks when payments are made. Maintains files and statistical records for use in monthly and annual reports. Performs other related work as assigned.
 
SUPPLEMENTAL INFORMATION
 FACTOR 1 – KNOWLEDGE REQUIRED BY THE POSITION Knowledge of the pertinent laws, regulations, and agency practices; and extensive ability to deal with persons on a face-to-face basis. Ability to type accurately. Ability to calculate payments of claims accurately. Ability to interview claimants and employers relative to claims and filing. Ability to assist in analyzing reports and claims. Ability to follow practices and procedures of other agencies relative to vouchers and payments of claimants. Ability to deal with the public effectively.FACTOR 2 – SUPERVISORY CONTROLS Work is closely reviewed for accuracy, adequacy and adherence to instruction and establish procedures.FACTOR 3 – GUIDELINESGuidelines consist of agency manuals of instructions and operations, local and national guidelines and codes as they relate to Worker's Compensation.FACTOR 4 – COMPLEXITYThe employee uses good judgment in verifying claims, and maintains accurate files to substantiate all actions taken on the claimant.FACTOR 5 – SCOPE AND EFFECT The purpose of this position is to investigate, and examine reports of employee's claims, and to determine if all claims meet the provision of the Worker's Compensation regulation; then determine what compensation must be administered to the client.FACTOR 6 – PERSONAL CONTACTSContacts are made with the general public, other government agencies, contractors, employers and co-workers.FACTOR 7 – PURPOSE OF CONTACTSContacts are made to obtain, verify, transmit or exchange factual information as they relate to clients.FACTOR 8 – PHYSICAL DEMANDSWork is mostly sedentary, but may require some walking and driving to activity site, and to agency to gather information to assist in the determination of compensation.FACTOR 9 – WORK ENVIRONMENTWork is performed primarily in an office setting.

Claims Adjuster II

TEEMA

<div>Overview: 
Our client, the largest Third Party Administrator in North America is looking for an experienced Claims Adjuster to handle Workers Compensation Claims. At the direction of the Claims Supervisor and/or Claims Manager, the Claims Adjuster/Examiner II / III manages all aspects of workers&rsquo; compensation indemnity, medical-only, future medical, and litigated claims from inception through resolution, within established authority and company/client guidelines. This role requires frequent interaction with clients, claimants, medical providers, attorneys, vendors, nurse case managers, vocational case managers, and internal staff. The level of complexity, litigation exposure, settlement authority, and leadership responsibility will be commensurate with the examiner&rsquo;s experience and designation (Level II or Level III). 
 
What you will be doing: 
Applies to Examiner II &amp; III<ul><li>
Manage a full caseload of workers&rsquo; compensation claims, including complex indemnity claims.</li><li>
Initiate, conduct, and document timely and thorough claim investigations.</li><li>
Determine compensability and administer benefits in accordance with state laws, rules, and company/client handling instructions.</li><li>
Manage medical treatment and medical billing; authorize services as appropriate.</li><li>
Communicate effectively with claimants, medical providers, vendors, and clients regarding claim issues.</li><li>
Compute and set reserves in accordance with Company and Client guidelines.</li><li>
Maintain an organized diary system and document claim files to reflect status, strategy, and action plans.</li><li>
Settle and/or finalize claims and obtain appropriate settlement authority.</li><li>
Conduct scheduled file reviews and respond to client inquiries.</li><li>
Identify injury trends, safety concerns, and other claim-related issues and communicate proactively to clients.</li><li>
Adhere to all company policies, procedures, and best practices.</li><li>
Utilize office systems and technology efficiently to manage caseload responsibilities.</li><li>
Perform other related duties as assigned.</li></ul>
Advanced / Senior Responsibilities (Primarily Examiner III)<ul><li>
Manage very complex, catastrophic, and litigated indemnity claims from inception to conclusion.</li><li>
Refer cases to outside defense counsel and actively participate in litigation strategy, hearings, mediations, and settlements.</li><li>
Identify and manage:<ul><li>
Subrogation opportunities</li><li>
Apportionment potential</li><li>
Excess reporting criteria and reimbursement</li></ul></li><li>
Prepare and assist with state audits, regulatory reporting, and client-specific reporting requirements.</li><li>
Develop and execute proactive claim strategies to drive timely and cost-effective resolution.</li><li>
Conduct detailed client file reviews and participate in client meetings as needed.</li><li>
Mentor and provide technical guidance to less experienced Claims Examiners.</li><li>
Handle multi-jurisdictional workers&rsquo; compensation claims as assigned.</li></ul> 
What you will be doing: 
Education &amp; Experience 
Claims Examiner II:<ul><li>
Bachelor&rsquo;s degree in a related field (preferred)</li><li>
Minimum 3+ years of workers&rsquo; compensation claims experience, or equivalent combination of education and experience</li></ul>
Claims Examiner III:<ul><li>
Minimum 5+ years of progressive workers&rsquo; compensation claims experience</li><li>
Demonstrated experience handling complex and litigated indemnity claims</li></ul>
Knowledge, Skills &amp; Abilities<ul><li>
Strong technical knowledge of workers&rsquo; compensation statutes, regulations, and medical terminology</li><li>
Ability to independently analyze and manage complex claims</li><li>
Excellent written and verbal communication skills</li><li>
Ability to convey technical information to claimants, clients, and internal stakeholders</li><li>
Strong organizational, analytical, and time-management skills</li><li>
Ability to interact professionally with individuals at all levels of the business environment</li><li>
Proficiency in Microsoft Word and Excel (preferred)</li></ul>
Certifications / Licenses<ul><li>
Hawaii Workers Compensation Adjusters License</li></ul> 

#Workwolf</div>

Workers Compensation Claims Examiner II/III - Hybrid

Jones Jones LLC

<div>Jones Jones LLC is a trusted leader in workers&rsquo; compensation defense, claims management, and regulatory compliance. With decades of industry experience, we proudly serve clients through our affiliated entities - NYTIC, Emerald, Mediation Resolution Management, and Medical Management Group - offering innovative solutions, collaborative teamwork, and unwavering professionalism. Our firm values growth, integrity, and excellence across every level of our organization.
We are seeking an experienced Claims Examiner who is interested in growing and expanding their expertise across multiple entities, including NYTIC, Emerald, Mediation Resolution Management and Medical Management Group. This unique cross-functional role offers exposure to complex claims, compliance, and ADR operation. This role is perfect for a skilled examiner seeking to broaden scope, strengthen leadership, and grow within a premier workers&rsquo; compensation firm.
The Firm is located at 5 Hanover Square, New York, NY and this is a hybrid position. 
Essential Functions 
1. Claims Adjusting Work (NYTIC / Emerald):<ul><li>
Perform intake and coverage verification via WCB employer coverage search</li><li>
Initiate three-point contact (employer/clamant/provider) within 24 hours</li><li>
Conduct compensability analysis and develop action plans</li><li>
Ensure timely filings: employer first report, EDI FROI/SROI via Emerald, PH-16.2, and C-240 wage statement</li><li>
Calculate AWW and benefit rates; set and review reserves at key milestones</li><li>
Monitor treatment against NY Medical Treatment Guidelines; manage MG-2 variance requests and C-8.1 objections</li><li>
Route medical bills to bill review and ensure fee schedule compliance</li><li>
Prepare for hearings and maintain eCase updates</li><li>
Evaluate resolution paths (SLU, LWEC, Section 32); manage subrogation and third-party notices</li></ul> 
2. Licensing &amp; Compliance (Jones Jones):<ul><li>
Collaborate with the Compliance team on licensing forms and regulatory filings</li><li>
Review TPA scorecards and ensure compliance with WCB standards</li><li>
Track and invoice licensing fees and renewals</li><li>
Support examiner training and respond to licensing-related inquiries</li></ul> 
3. ADR (MRM):<ul><li>
Manage intake, eligibility, and notices under the collectively bargained ADR program</li><li>
Coordinate and schedule mediations</li><li>
Draft case summaries and settlement proposals</li><li>
Ensure adherence to Medical Network protocols and document variances</li><li>
Prepare and route settlement paperwork, including Section 32 agreements</li><li>
Maintain dashboards of ADR cycle times and outcomes for annual reporting</li><li>
Obtain loss runs from wrap-up sponsors</li></ul> 
4. MMG<div><ul><li>
Evaluate Independent Medical Examination (IME) reports for accuracy and compliance</li></ul></div><ul><li>
Assist with administrative tasks such as schedule coordination and provider panel management</li></ul> 
Competencies<ul><li>
Excellent and professional verbal and written communication skills</li><li>
Strong understanding of workers&rsquo; compensation best practices</li><li>
Exceptional organizational skills and attention to detail</li><li>
Excellent time management skills with a proven ability to meet deadlines</li><li>
Strong analytical and problem-solving skills</li><li>
Ability to perform well in a fast-paced, dynamic environment</li><li>
Ability to maintain confidentiality and exercise discretion and sound judgment</li><li>
Proficient with Microsoft Office Suite or related software</li></ul> 
Qualifications<ul><li>
Bachelor&rsquo;s degree in business administration or related field</li><li>
Active Independent Adjuster License (required)</li><li>
 2- 5 years of claims management experience</li></ul> 
Apply today to join a firm with over a century of success and a future focused on innovation. Jones Jones LLC is an equal employment opportunity employer.</div>

Claims Examiner

<div>Job Summary
Workers Compensation Claims Examiner III
TeemaGroup
Full-time
In-Office | Kapolei, HI, United States 
POSITION SUMMARY
At the direction of the Claims Supervisor and/or Claims Manager, the Claims Examiner II / III manages all aspects of workers&rsquo; compensation indemnity, medical-only, future medical, and litigated claims from inception through resolution, within established authority and company/client guidelines.
This role requires frequent interaction with clients, claimants, medical providers, attorneys, vendors, nurse case managers, vocational case managers, and internal staff.
The level of complexity, litigation exposure, settlement authority, and leadership responsibility will be commensurate with the examiner&rsquo;s experience and designation (Level II or Level III).
DUTIES AND RESPONSIBILITIES
Core Responsibilities (Applies to Examiner II &amp; III)<ul><li>Manage a full caseload of workers&rsquo; compensation claims, including complex indemnity claims.</li><li>Initiate, conduct, and document timely and thorough claim investigations.</li><li>Determine compensability and administer benefits in accordance with state laws, rules, and company/client handling instructions.</li><li>Manage medical treatment and medical billing; authorize services as appropriate.</li><li>Communicate effectively with claimants, medical providers, vendors, and clients regarding claim issues.</li><li>Compute and set reserves in accordance with Company and Client guidelines.</li><li>Maintain an organized diary system and document claim files to reflect status, strategy, and action plans.</li><li>Settle and/or finalize claims and obtain appropriate settlement authority.</li><li>Conduct scheduled file reviews and respond to client inquiries.</li><li>Identify injury trends, safety concerns, and other claim-related issues and communicate proactively to clients.</li><li>Adhere to all TRISTAR company policies, procedures, and best practices.</li><li>Utilize office systems and technology efficiently to manage caseload responsibilities.</li><li>Perform other related duties as assigned.</li></ul>
Advanced / Senior Responsibilities (Primarily Examiner III)<ul><li>Manage very complex, catastrophic, and litigated indemnity claims from inception to conclusion.</li><li>Refer cases to outside defense counsel and actively participate in litigation strategy, hearings, mediations, and settlements.</li><li>Identify and manage:</li><li>Subrogation opportunities</li><li>Apportionment potential</li><li>Excess reporting criteria and reimbursement</li><li>Prepare and assist with state audits, regulatory reporting, and client-specific reporting requirements.</li><li>Develop and execute proactive claim strategies to drive timely and cost-effective resolution.</li><li>Conduct detailed client file reviews and participate in client meetings as needed.</li><li>Mentor and provide technical guidance to less experienced Claims Examiners.</li><li>Handle multi-jurisdictional workers&rsquo; compensation claims as assigned.</li></ul>
Essential job functions.
QUALIFICATIONS REQUIRED
Education &amp; Experience<ul><li>Claims Examiner II:</li><li>Bachelor&rsquo;s degree in a related field (preferred)</li><li>Minimum 3+ years of workers&rsquo; compensation claims experience, or equivalent combination of education and experience</li><li>Claims Examiner III:</li><li>Minimum 5+ years of progressive workers&rsquo; compensation claims experience</li><li>Demonstrated experience handling complex and litigated indemnity claims</li></ul>
#Workwolf</div>

Workers Compensation Claims Examiner III

<div>ADP is hiring a Lead Claims Examiner. In this position you will perform the following basic functions:
<ul><li>Supervisory responsibility for Claims Examiner I and Senior Examiner</li>
<li>To aid in overall claim cost reduction by coordinating efforts between all involved vendors, clients and WES.</li>
<li>Additional level to monitor applicable claims assigned to Claims Examiner I and Senior Examiner</li>
<li>To ensure TPA/Carrier accountability in agreed performance standards and coordinate needs for changes with Claims Director</li>
<li>To accumulate data for the purpose of creating standards for measurement of various claim related issues, as well as customer service and internal staff performance</li>
</ul>At ADP we are driven by your success. We engage your unique talents and perspectives. We welcome your ideas on how to do things differently and better. In your efforts to achieve, learn and grow, we support you all the way. If success motivates you, you belong at ADP. 
 
We strive for every interaction to be driven by our CORE values: Insightful Expertise, Integrity is Everything, Service Excellence, Inspiring Innovation, Each Person Counts, Results-Driven, - Social Responsibility. 
 
RESPONSIBILITIES:
<ul><li>Reviews and recommends acceptability of all Workers' Compensation Claims within claim distribution</li>
<li>Accountability for the Claim Unit's efforts in all RTW efforts, OSHA documentation and all documentation of claim activity according to stated claim procedures.</li>
<li>Works directly with Claims Director to determine workloads and the necessity of procedure changes within the Claims Unit</li>
<li>Assists in online audits of TPA to insure quality compliance of claim procedures and client satisfaction in Workers' Compensation claims handling.</li>
<li>Maintaining e-time and PTO/Sick time coordination for the Claims Unit., has one administrative direct report and mentor/coaching responsibilities for the Claims Examiner.</li>
<li>Responsible for communication with internal/external clients, claimants, related vendors as well as TPA/Carrier activity for TotalSource work-site employee claims to include personal visits to each region.</li>
<li>Requires basic knowledge of Workers' Compensation laws for all jurisdictions.</li>
<li>Attends professional development courses and seminars to keep TotalSource current with related workers' compensation laws and standards.</li>
<li>Represents client in legal activities related to Workers' Compensation Claims within authority.</li>
<li>To review, audit and support the examiner positions.</li>
<li>To generate routine reports for productivity level evaluation.</li>
<li>To support the Claims Director in daily/monthly/quarterly tasks and projects that aid in the claim operation reach it's specified goals.</li>
</ul>QUALIFICATIONS REQUIRED:
<ul><li>5+ years in WC Indemnity adjusting or industry related experience</li>
<li>Experience with complex claims cases</li>
</ul>PREFERRED QUALIFICATIONS: Preference will be given to candidates who have the following:
<ul><li>Direct or indirect leadership experience</li>
<li>PEO experience
</li><li>Maintain knowledge of basis Workers Compensation Laws in all applicable jurisdictions</li>
<li>Stay abreast of strategies and current industry related ideologies in dealing with Workers' Compensation Claims</li>
<li>Maintain adequate resources to enable continued education in Workers' Compensation and RTW issues.</li>
</ul>#LI-KD1
#LI-Remote
<div>Base salary offers for this position may vary based on factors such as location, skills, and relevant experience. Some positions may include additional compensation in the form of bonus, equity or commissions. We offer the following benefits: Medical, Dental, Vision, Life Insurance, Matched Retirement Savings, Wellness Program, Short-and Long-Term Disability, Charitable Contribution Match, Holidays, Personal Days &amp; Vacation, Paid Volunteer Time Off, and more. The compensation for this role is USD $59,100.00 - USD $120,200.00 / Year* 
 
<ul><li>Actual compensation will not be less than the applicable minimum wage or minimum exempt salary requirement under federal, state and local laws.</li></ul> 
</div>A little about ADP: We are a comprehensive global provider of cloud-based human capital management (HCM) solutions that unite HR, payroll, talent, time, tax and benefits administration and a leader in business outsourcing services, analytics, and compliance expertise. We believe our people make all the difference in cultivating a down-to-earth culture that embraces our core values, welcomes ideas, encourages innovation, and values belonging. We've received recognition for our work by many esteemed organizations, learn more at ADP Awards and Recognition.
Diversity, Equity, Inclusion &amp; Equal Employment Opportunity at ADP: ADP is committed to an inclusive, diverse and equitable workplace, and is further committed to providing equal employment opportunities regardless of any protected characteristic including: race, color, genetic information, creed, national origin, religion, sex, affectional or sexual orientation, gender identity or expression, lawful alien status, ancestry, age, marital status, protected veteran status or disability. Hiring decisions are based upon ADP&rsquo;s operating needs, and applicant merit including, but not limited to, qualifications, experience, ability, availability, cooperation, and job performance.
Ethics at ADP: ADP has a long, proud history of conducting business with the highest ethical standards and full compliance with all applicable laws. We also expect our people to uphold our values with the highest level of integrity and behave in a manner that fosters an honest and respectful workplace. Click https://jobs.adp.com/life-at-adp/ to learn more about ADP&rsquo;s culture and our full set of values.</div>

Workers' Comp Claims Lead Examiner

TEEMA Group

<div><h2 class="jobSectionHeader">Workers&rsquo; Compensation Claims Examiner III</h2>
 Irving, TX (On-Site) 
 $36.53 &ndash; $38.46 per hour 
 Contract: 3&ndash;4 Months (Potential Extension)<h3 class="jobSectionHeader">
Overview</h3>
We are seeking an experienced Workers&rsquo; Compensation Claims Examiner III to join a high-volume claims environment in Irving, Texas. This position is fully on-site and requires in-office attendance five (5) days per week.
The ideal candidate will have strong expertise handling Texas Workers&rsquo; Compensation indemnity claims and the ability to manage claims from inception through resolution with minimal supervision. This role requires excellent organization, regulatory knowledge, and the ability to collaborate with internal teams, claimants, employers, and legal representatives.
This is a great opportunity for an experienced claims professional seeking exposure within a large, well-established organization.<h3 class="jobSectionHeader">
What You Will Be Doing</h3><ul><li>Manage Texas Workers&rsquo; Compensation loss-time claims from inception through closure</li><li>Investigate claims to determine compensability and coverage</li><li>Administer indemnity and medical benefits in accordance with Texas Workers&rsquo; Compensation regulations</li><li>Evaluate claim exposure and maintain accurate claim documentation</li><li>Prepare formal captioned reports and maintain compliant claim files</li><li>Communicate professionally with claimants, employers, attorneys, and internal stakeholders</li><li>Assist employers and injured workers in understanding the Workers&rsquo; Compensation process</li><li>Ensure claims handling follows internal best practices and client guidelines</li><li>Maintain strong organization while managing a high-volume caseload</li><li>Deliver excellent customer service throughout the entire life of the claim</li></ul><h3 class="jobSectionHeader">
What You Must Have</h3>
✔ Active Texas Workers&rsquo; Compensation Adjuster License 
✔ 5+ years of Texas Workers&rsquo; Compensation claims handling experience 
✔ Experience handling loss-time claims 
✔ Experience with public entity and First Responder claims preferred 
✔ Strong understanding of Texas Workers&rsquo; Compensation laws and regulations 
✔ Excellent written and verbal communication skills 
✔ Ability to manage multiple claims in a fast-paced environment 
✔ High School Diploma or GED required 
✔ Bachelor&rsquo;s Degree preferred<h3 class="jobSectionHeader">
Work Environment</h3><ul><li>Full-time on-site role (no remote or hybrid)</li><li>Collaborative office environment</li><li>Daily interaction with internal teams and external stakeholders</li><li>Use of standard office equipment including computer systems and claims management software</li></ul><h3 class="jobSectionHeader">
Additional Requirements</h3><ul><li>Ability to pass background check and drug screening</li><li>Must be authorized to work in the United States</li></ul><h3 class="jobSectionHeader">
Apply Today</h3>
If you are an experienced Texas Workers&rsquo; Compensation Claims Examiner looking for an opportunity to contribute your expertise in a fast-paced claims environment, we encourage you to apply today.
Email your resume
mpalkin@teemagroup.com
#Workwolf</div>

Workers Compensation Claims Examiner

Cala Sourcing Solutions LLC

<div><h3 class="jobSectionHeader">Workers&rsquo; Compensation Claims Examiner III (Contract)</h3>
Please no 3rd party recruiters, or C2C.
Location: Irving, TX 
Schedule: On-site | Monday&ndash;Friday (5 days/week) - only local candidates will be considered 
Pay Rate: $36.53 &ndash; $38.46 per hour 
Contract Length: 3&ndash;4 months (with potential extension)<h4 class="jobSectionHeader">
About the Role</h4>
We&rsquo;re looking for a seasoned Workers&rsquo; Compensation Claims Examiner III to step into a fast-paced, high-volume environment and take ownership of Texas loss-time claims from start to finish. This role is ideal for an experienced examiner who is confident working independently, thrives in an in-office setting, and understands the importance of accuracy, urgency, and strong communication.
This is a fully on-site position in Irving, TX. Daily in-person collaboration with colleagues and stakeholders is a core part of the role&mdash;remote or hybrid work is not available.<h4 class="jobSectionHeader">
What You&rsquo;ll Be Doing</h4><ul><li>
Handle Texas Workers&rsquo; Compensation indemnity claims from initial intake through resolution</li><li>
Analyze coverage, investigate facts, and make compensability determinations in compliance with Texas statutes</li><li>
Administer indemnity and medical benefits within assigned authority levels</li><li>
Apply internal best practices and client-specific handling guidelines consistently</li><li>
Prepare and maintain detailed, captioned claim reports and documentation</li><li>
Serve as a key point of contact for claimants, employers, attorneys, and internal partners</li><li>
Clearly explain the claims process to employers and injured workers, setting expectations throughout the claim lifecycle</li><li>
Maintain accurate, timely claim files while balancing multiple deadlines</li><li>
Deliver a high level of customer service in a regulated, deadline-driven environment</li></ul><h4 class="jobSectionHeader">
What We&rsquo;re Looking For</h4><ul><li>
Active Texas Workers&rsquo; Compensation Adjuster License (required)</li><li>
5+ years of hands-on Texas Workers&rsquo; Compensation claims experience</li><li>
Prior experience handling public entity and First Responder claims</li><li>
Strong working knowledge of Texas Workers&rsquo; Compensation laws and regulations</li><li>
Excellent written and verbal communication skills</li><li>
Ability to manage a full caseload with minimal supervision</li><li>
High School Diploma or GED required</li><li>
Bachelor&rsquo;s degree in a related field preferred</li></ul><h4 class="jobSectionHeader">
Work Environment &amp; Expectations</h4><ul><li>
100% on-site role in a professional office setting</li><li>
Frequent interaction with internal teams and external stakeholders</li><li>
Use of standard office equipment and claims management systems</li><li>
Consistent, full-time in-office attendance required</li></ul><h4 class="jobSectionHeader">
Additional Requirements</h4><ul><li>
Ability to pass a background check and drug screening</li><li>
Authorization to work in the United States</li></ul>
#Workwolf</div>

Worker's comp/Claims examiner III

Search 10000+ Worker's compensation claims examiner jobs near you this March. New roles added regularly across leading industries. Apply today.