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At Redwood Empire Schools’ Insurance Group (RESIG), we have you covered—one student, one school, one district at a time—supporting the evolving needs of our members with professionalism and excellence. Since 1979, RESIG has been protecting our students, staff, and school districts with exceptional programs, resources, and services.
Annual Salaries:
$94,326 - $120,388 (DOE) – Senior Claims Examiner
$78,608 - $100,325 (DOE) – Claims Examiner
WORKERS’ COMPENSATION SENIOR CLAIMS EXAMINER
(EXEMPT POSITION)
Definition
This is an advanced Claims Examiner position. Under the general supervision of the Workers’ Compensation Manager and Claims Supervisor, this position is responsible for the investigation, evaluation, and settlement of claims.
Principle Job Duties
• In accordance with claims management procedures, review, investigate, and manage workers’ compensation claims for member school districts with use of a computerized claims management system.
• Obtain all documentation to substantiate the facts surrounding a claim.
• Evaluate and analyze the extent of exposure to accurately reserve claims.
• Analyze, make recommendations, and approve medical treatment plans from treating physicians and providers.
• Administer claim settlement authority according to policy.
• Administer statutory benefits to injured workers.
• Identify and pursue potential subrogation.
• Identify excess insurance claims, prepare reports to excess insurance carriers, and process reimbursements.
• Prepare concise reports for attorneys, physicians, member districts, and management.
• Provide status update to management on complex and/or sensitive claims.
• Develop and conduct periodic file reviews with member districts.
• Prepare claims for defense, settlement, subrogation, or arbitration activity.
• Provide direction to defense counsel, investigators, and vendors. Monitor and control claims costs.
• Delegate non-essential and/or clerical work to Claims Assistants and clerical support staff.
• Develop and implement strategy to manage claims to an accurate and timely conclusion.
• Provide backup to Claims Examiners in their absence.
WORKERS’ COMPENSATION CLAIMS EXAMINER
(NON-EXEMPT POSITION)
Definition
Under direct supervision of the Workers’ Compensation Manager, this position is responsible for the investigation and evaluation of claims assigned. Assignments will be made using the following criteria and at the discretion of the Workers’ Compensation Manager.
• Medical only claims exceeding 1 or 2 medical visits.
• Future medical claims deemed appropriate by the Workers’ Compensation Manager.
• Any loss deemed appropriate pursuant to the discretion of the Workers’ Compensation Manager.
Principal Job Duties
• In accordance with claims management procedures, reviews, investigates, and processes workers’ compensation claims for member school districts with use of a computerized claims management system.
• Obtain all documentation to substantiate the facts surrounding a claim – i.e., medical bills, medical reports, investigation reports.
• Evaluate and analyze extent of claim to accurately reserve a file.
• Identify and pursue subrogation potential.
• Prepare concise reports, when required, to physicians.
• Keep appropriate school districts personnel and management advised of file status as required.
• Maintain close communication with management on work in progress and sensitive issues.
• Determine need for and provide direction to investigators. Monitor and control their costs.
• Perform related duties as assigned.
WORKERS’ COMPENSATION SENIOR CLAIMS EXAMINER
(EXEMPT POSITION)
Knowledge and Skills
• W/C claim adjusting, investigation, and administrative techniques necessary to manage claims from initial report of injury to settlement or closure.
• California Labor Code, Government Code, and Education Code sections relative to workers’ compensation benefits.
• Reserving practices and techniques in accordance with laws sufficient to establish and maintain adequate financial levels on all claims, with understanding of excess carrier reporting.
• Office methods and equipment, audio visual equipment, filing systems, telephone techniques, letter and report writing, and well-developed computer skills required in Windows-based applications.
• Computer skills sufficient to manage workers’ compensation claims using an internal data processing system, including imaging system.
Ability to
• Organize, develop, and prepare claims for assignment to counsel, trial, and mandatory settlement conferences.
• Learn, interpret, and apply specific rules, laws, and policies necessary to apply them with good judgement in the administration of public entity claims.
• Establish and maintain cooperative relationships with peers, managers, and those contacted in the course of work.
• Analyze claim developments and adopt effective courses of action necessary to close claims.
• Work independently and/or collaborate with RESIG management.
• Represent RESIG in a manner consistent with the policies, practices, and procedures of the organization.
• Attend conferences, off-site trainings, seminars, and other work-related events.
• Communicate effectively, both verbally and in writing.
• Independently and effectively organize and prioritize workload with frequent interruptions.
• Obtain and maintain CA Self-Insurance Administrator’s Certificate within the first year of assuming the Workers’ Compensation Senior Claims Examiner position.
Working Conditions
• Ability to travel to various schools, vendors, meeting sites, and conferences.
• Must provide means of transportation.
• Must provide proof of a valid California driver’s license and California vehicle insurance.
• Work while sitting, standing, bending, stooping, squatting, kneeling, and climbing.
• Work with office equipment and computerized workstation, which involves repetitive arm and hand movement.
• Lift and carry up to 25 pounds.
Experience and Education
• A minimum of 3 years experience of increasingly complex w/c claims adjusting/examining.
• A California Self-Insured Administrator’s Certificate is preferred.
• High School Diploma or equivalent required; college degree preferred.
• Experience with the public sector or public schools is desirable.
WORKERS’ COMPENSATION CLAIMS EXAMINER
(NON-EXEMPT POSITION)
Knowledge of
• Workers’ Compensation claims adjusting, investigation, and administrative techniques necessary to carry management of claims from reporting of injury to closure.
• California Labor Code, Government Code and Education Code sections relative to workers’ compensation benefits.
• Reserving practice and techniques sufficient to set and maintain responsible levels on all claims, with awareness of excess carrier reporting requirements.
• Office methods and equipment, filing systems, telephone techniques, letter and report writing.
• Computer skills sufficient to manage workers’ compensation claims using an internal data processing system.
Ability to
• Learn, interpret, and apply specific rules, laws, and policies necessary in the administration of public entity workers’ compensation claims.
• Establish and maintain cooperative relationships with peers, managers, and those contacted in work.
• Analyze situations and adopt effective course of action working independently and with both verbal and written direction.
• Represent RESIG to service providers and others in a manner consistent with the policies, practices, and procedures of the organization.
• Communicate effectively, organize, and prioritize workload.
• Obtain and maintain CA Self-Insurance Administrator’s Certificate within the first year of assuming the Workers’ Compensation Claims Examiner position.
Working Conditions
• Work with office equipment and computerized workstation.
• Work while sitting, standing, bending, stooping, squatting, and kneeling.
• Be able to communicate verbally and in writing with co-workers and district contacts.
Experience and Education
• 1 to 2 years experience of workers’ compensation claims examiner or claims examiner trainee experience.
• A California Self-Insured Administrator Certificate is preferred
• High School Diploma or equivalent required; college degree preferred.
• Experience with the public sector or public schools is desirable.
