The Senior Claims Adjuster investigates, evaluates, negotiates, and concludes office handled worker’s compensation lost time claims. This position is responsible for resolving problems and answering inquiries from members, providers, claimants, and their representatives.
- Manages all types of complex claims, including but not limited to lost time.
- Independently analyzes case facts to establish timely and accurate reserves. Requires knowledge of medical disabilities and related costs, as well as likely duration of claim.
- Conducts prompt and thorough investigation of case facts. Interprets and applies appropriate statutes, regulations and case law to determine compensability.
- Recognizes potential for subrogation and places appropriate parties on notice.
- Make timely and accurate payment of benefits and ensure accurate and timely processing of required EDI-R3 filings with the State.
- Manages and documents medical treatment and takes necessary actions to bring claim to closure including obtaining necessary authority to set appropriate reserves and settlement amounts.
- Notifies Reinsurers when claims and or reserves reach certain levels per company standards and provide updates as necessary
- Follows-up with medical providers and employer regarding injured workers’ progress. Ensures quality case and medical management by applying appropriate medical concepts, and by interpreting and applying appropriate statutes and regulations.
- Requires a high degree of independent judgment to apply facts of case and render accurate decisions.
- Supports the process by scheduling medical or testing appointments and providing authorizations.
- Demonstrates sound medical management skills and aggressive claims handling, proactively pursuing return to work.
- Reviews case facts to identify possible fraud throughout the course of the claim.
- Reviews and approves or denies medical bills.
- Completes regular claim reviews with a clear plan of action addressing ongoing claim management, reserve adequacy and rationale to facilitate quick resolutions and the best possible outcome.
- Attends mediations and obtains settlement authority from clients.
- Manages litigation by providing detailed investigative material to respective defense attorneys.
- Makes recommendations to defense attorney on litigation strategy in order to develop the best strategy and outcome.
- Ensures that petition for benefits are responded on a timely basis. Follows adjuster diaries for timely completion of routine claim functions e.g. indemnity payments, all required state filings, claim status report due dates, claim reviews.
- Mentors less experienced claim adjusters.
- Maintains professional and technical knowledge by attending appropriate CEUs and training classes.
- Performs other duties as assigned.
- Excellent communication and interpersonal skills; expresses thoughts and ideas clearly, both verbally and in writing; establishes trust and confidence quickly.
- Able to comprehend simple written and oral instructions.
- Basic skills in Microsoft Office (primarily Word and Excel). Must be computer literate with the ability to learn new software applications.
- Ability to function effectively under tight time constraints, consistently meet strict deadlines, prioritize, and handle multiple tasks in a demanding work environment.
- Ability to communicate appropriately and build professional relationships with employees at all levels of the organization.
- Willingness to adhere to all principles of confidentiality.
- Ability to represent the company in a professional manner to both internal and external customers and clients.
- Ability to maintain a high level of tact and professionalism.
EDUCATION AND QUALIFICATIONS
- High School Diploma, college degree preferred or one to two years related experience or equivalent combination of education and experience.
- One to three years of workers’ compensation claims experience.
- Workers’ Compensation Adjuster License or All-lines Adjuster License