Job Description

The Senior Claims Adjuster is responsible for managing complex workers compensation claims and assisting the process of determining benefits due the injured worker, ensure ongoing adjudication of claims within company standards and industry best practices and comply with all statutory and regulatory requirements for the administration of workers compensation benefits on behalf of the Company.

KEY RESPONSIBILITIES AND ESSENTIAL FUNCTIONS:

• New Claims: All new lost time claims require an initial contact with the employer, the injured worker and the medical provider. This must be done within 24 hours of receipt of the claim or notification of a claim.
• Ensure that all claim determinations and payments are completed timely including but not limited to, acceptance/denial letters, wage determination letters including required enclosures and appeal forms. In jurisdictions requiring the letters be provided in Spanish and English the adjuster is responsible to make sure all letters are completed.
• The initial payment of TTD is to be completed within 14 days from the receipt of an accepted claim. Wage information is to be solicited from the employer and either an average weekly wage or average monthly (jurisdiction dependent) be established and the information documented in Claims System. In the event actual payroll documentation cannot be obtained from the employer an “estimated wage” is established and a payment reconciliation is done when the verified wage is secured. Initial compensation benefits should NOT be delayed due to the failure of the employer to provide wage documentation.
• Timely claims determinations for all services including but not limited to: acceptance, denials, authorizations for treatment, benefit payment start, termination are to be included within the statutory or regulatory time frames of the jurisdiction. Denials requiring certified mailing are to be completed timely with appropriate tracking.
• Regulatory notices are to be completed timely when required by jurisdictions.
• Approvals and denials of medical bills should be completed within 24 hours of receipt so bills can be repriced and paid timely.
• Identify the medical providers and medical treatment plan and ensure timely and appropriate medical care is provided to the injured worker. In cases requiring complex or unusual medical care a nurse case manager is to be assigned to facilitate the timely and appropriate care.
• All communications with all parties and reference to all determinations and correspondence are to be included in the claim notes of Claim System. Each office is “paperless” offices, and all documents need to be scanned and added to the claim claims system and a claim note generated. notes.
• Manage the legal aspects of the claim and appropriately assign and direct designated attorneys.
• Assign claims for investigations, including surveillance, medical surveys and social media checks when required and seek supervisor support on related questions.
• Ensure that all bills for various expenses, including legal bills, managed care bills and similar expenses are paid timely or direct claims assistants to pay such when appropriate.
• Answer phone calls immediately when in the office. Return all calls and voice mail messages with 24 hrs. Respond to all e-mails when required within 24 hrs.
• Direct claims assistants to facilitate adjuster assignments as required. This includes directing clerical staff in duties such as copying documents, scheduling medical appointments for injured workers and filing of documents. Coordinate assignments with the supervisor of the assistants.
• Establish a Plan of Action (POA) on each claim and update the POA monthly.
• Monitor claims for reinsurance/excess insurance reporting and provide initial reports and quarterly updates on all claims meeting reporting requirements.
• Performs other activities, assignments and duties as assigned.

Requirements

MINIMUM QUALIFICATIONS:

• High school diploma or GED required
• Bachelor’s degree or equivalent experience preferred
• 5 or more years’ claims experience preferred
• Insurance industry knowledge required
• Excellent analytical skills and verbal and written communication skills
• Strong organizational skills
• Strong oral and written communication skills