Job Summary
The Workers Compensation Claims Adjuster is responsible for managing all aspects of a 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
- 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 and diaries future payments as appropriate
- Orders independent medical examination as necessary and prepares all relevant documentation for physician review
- Maintains regular correspondence with claimants, insureds, and nurse case manager to include claim updates, medical appointments, or issues with disability payments
- Reviews and processes medical bills through third-party vendor for additional discount opportunities
- Aggressively collaborates with claimants 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 which includes providing all relevant claim documentation needed for defense counsel to successfully defend claim and evaluate ultimate claim exposure.
- Attends settlement conferences, mediations, and hearings on behalf of the insurance company/insured.
- 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 and 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
- Other duties as assigned
