Senior Workers Compensation Adjuster - Remote CST/EST

Job Summary

The Workers Compensation Claims Adjuster is responsible for managing all aspects of a State Act workers compensation claim which includes determining compensability, verifying coverage, administering disability and medical benefits, skillfully negotiating claim resolutions, troubleshooting and assisting injured employees, employers and medical/legal professionals with any service needs throughout the lifespan of a claim.

Essential Functions

• Receives newly reported claims
• Determines coverage under the State WC Act, and any exposure to LHWCA
• Maintains and updates claim notes throughout lifespan of claim
• Records claim information in electronic database
• Interviews claimants, insureds, medical professionals and witnesses to determine claim validity
• Communicates claim compensability decisions to claimant, employer and medical provider
• Sets appropriate reserves based on nature/extent of injury
• Calculates lost time wages, makes disability payments directly to claimants. Diaries future payments as appropriate.
• Reports all mandatory claims data directly to State entities within required timeframes
• Orders independent medical examination as necessary and prepares all relevant documentation for physician review
• Maintains regular correspondence with claimants, insureds, clients, and nurse case manager to include claim updates, medical appointments, or issues with disability payments.
• Reviews and processes medical bills for additional discount opportunities
• Aggressively collaborates with claimants, clients and insureds to ensure early return-to-work is pursued.
• Works in partnership with legal counsel to warrant that insured's interests are protected on litigated claims. This includes providing all relevant claim documentation needed for defense counsel to successfully defend claim and evaluate ultimate claim exposure.
• Attend settlement conferences, mediations, and hearings on behalf of the insurance company
• Reviews and approves defense attorney bills within authority
• Works with underwriting to help provide relevant information on losses for renewal rates as well as Risk Management to identify trends. Also, may interact with agents for insureds on losses
• Responds to State requests for health cost disputes, applications for hearings and penalty assessment letters
• Identifies subrogation potential and pursues recovery
• Leads claim reviews with clients as requested

Knowledge, Skills and Abilities

• Proficiency in entire Microsoft Office suite
• Knowledge of relevant workers' compensation laws
• Strong grasp of medical terminology
• Familiarity with medical cases and how treatment typically progresses
• Excellent professional oral and written communication abilities
• Attention to detail and good organization skills
• Ability to negotiate issues and settlements
• Strong focus on customer service which includes timely response to requests/inquiries
• Ability to adapt to changing technologies and learn functionality of new equipment and systems
• Ability to establish and maintain effective working relationships with others

Required Education and Experience

• 5-10 years experience handling high level claims
• Experience and current adjusters license to handle WC claims in AR, DC, IL, LA, MN, NJ, SC, TN, TX, WI.
• High School education

Benefits

• Medical, dental, and vision insurance
• Life insurance
• 401(K) with match