Workers' Comp Medical Only Adjuster

Location: Home United States

About the role

Davies North America is seeking an experienced Medical Only Adjuster to join our claims team. This position is responsible for investigating, evaluating, and managing assigned workers’ compensation medical-only claims in accordance with company standards, client expectations, and applicable state regulations. The ideal candidate will have a strong understanding of workers’ compensation claims handling, Florida workers’ compensation statutes, medical terminology, claim investigation, reserving, and return-to-work coordination. This role requires sound judgment, strong communication skills, and the ability to manage claims proactively while delivering excellent service to injured workers, employers, clients, and medical providers.

Responsibilities

• Investigate assigned workers’ compensation claims by completing timely contact with injured workers, employers, physicians, witnesses, and other involved parties.
• Evaluate claim details, applicable statutes, case law, and medical information to determine compensability and claim value.
• Set and maintain appropriate reserves for the life of the claim using applicable tools, guidelines, and company reserving practices.
• Provide benefits and initiate required state filings in a timely and accurate manner.
• Monitor medical treatment in coordination with Nurse Case Managers when assigned.
• Review, document, and approve medical bills for payment within required timeframes.
• Authorize appropriate medical services in accordance with applicable workers’ compensation statutes and claim requirements.
• Maintain regular contact with injured employees to support claim progression and customer service.
• Coordinate light duty availability and reasonable accommodations with employers and medical providers.
• Review assigned impairment ratings for accuracy and take appropriate action, including transferring claims or initiating impairment benefits and filings when required.
• Maintain claim diaries, workflow requirements, and accurate file documentation.
• Review claims for potential red flags, compensability concerns, and escalation needs.
• Identify and pursue subrogation, contribution, indemnification, or other recovery opportunities when applicable.
• Adhere to client-specific claim handling instructions and service expectations.
• Attend client meetings as needed and maintain regular communication to support client satisfaction.
• Negotiate claim settlements when appropriate.
• Make timely notice to excess carriers when claims meet reporting criteria and provide ongoing updates as needed.
• Maintain required continuing education credits and licensing requirements.
• Report account, client, E&O, or quality concerns to appropriate management.
• Maintain a positive, team-oriented approach while delivering high-quality service to clients and claimants.
• Perform other duties as assigned by claims leadership.

Requirements

• Prior experience handling workers’ compensation claims.
• Working knowledge of workers’ compensation laws, rules, procedures, and claim handling practices.
• Familiarity with Florida Workers’ Compensation Statute and related claim requirements preferred.
• Strong understanding of medical terminology, medical procedures, and treatment documentation.
• Ability to evaluate compensability, claim exposure, reserves, and benefit entitlement.
• Strong written and verbal communication skills.
• Excellent organizational skills with the ability to manage diaries, deadlines, and workflow requirements.
• Ability to exercise discretion, independent judgment, and sound decision-making.
• Proficiency with Microsoft Office Suite, including Word, Excel, and Outlook.
• Ability to learn and effectively use claims management systems and related business software.

Qualifications

• Florida workers’ compensation claims handling experience.
• Experience handling medical-only workers’ compensation claims.
• Prior TPA experience.
• Experience with claim systems, medical bill review, ISO, and workers’ compensation reserving tools.
• Knowledge of subrogation, contribution, indemnification, and excess carrier reporting.
• Experience participating in client meetings or claim reviews.

Benefits

• Medical, dental, and vision plans to support your health and that of your family.
• A 401(k) plan with employer matching.
• Time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non-exempt employees.
• Paid holidays.
• Life insurance and short-term and long-term disability coverage.

Benefit offerings, eligibility, and required employer contributions may vary based on role, classification, and applicable federal, state, and local laws, including those tied to an employee’s primary work location. Where required by law, the Company provides paid sick leave, paid family and parental leave, and other mandated benefits in accordance with applicable state and local requirements.

Pay

$49,500 - $55,000 / year