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Hybrid Senior Workers Compensation Claims Adjuster
Posted 3 weeks ago
About the role
- Manage a caseload of limited coverage and medium to severe claims with authorization to resolve cases within a designated monetary threshold.
- Develop and implement impactful strategies to negotiate and resolve claims within established parameters.
- Strive to achieve fair and equitable outcomes while steadfastly upholding company and departmental protocols and standards.
- Deliver quality customer service to all parties involved in the claim process, ensuring prompt and efficient delivery of appropriate benefits.
- Actively participate in meetings or visits with agents, insurers, and policyholders to cultivate professional relationships and facilitate effective issue resolution.
- Conduct investigations into losses utilizing various techniques such as interviews, recorded statements, and thorough documentation.
- Diligently gather and preserve evidence.
- Identify opportunities for subrogation or instances of potential fraud.
- Verify, analyze, and apply coverage correctly to each case based on a thorough analysis of facts and pertinent statutory case law.
- Scrutinize bills, determine necessary actions, and process claims accordingly, prioritizing cost-effective resolutions.
- Prepare concise and timely reports to facilitate efficient claims processing.
- Keep agents, insurers, agency operations, and the corporate Claims Department informed of file status and pertinent developments.
- Ensure accurate and timely filing of all state forms required for claims processing; prepare necessary reports for large loss and reinsurance carriers.
- Establish reserves and authorize payments in alignment with established procedures.
- Scrutinize contracts to evaluate risk transfer and assess duty to defend and indemnify additional insured parties.
- Manage the litigation process in an efficient and effective manner.
- Determine the necessity for, and provide guidance to defense counsel, independent adjusters, or technical experts, while monitoring and managing their expenses.
- Attend hearings, pre-trial settlements, conferences and trials.
- Assess the need for independent medical evaluations, second opinions, nurse or physician reviews, and make referrals.
- Evaluate the need for external services such as surveillance, field adjusters, or field case managers or coordinating referrals.
- Maintain detailed documentation of claims activity in claim notes, regularly reviewing and updating diaries and claim notes for all open claims.
- Meet or exceed expected quality performance guidelines to uphold service standards.
- Participate in professional development through training programs to stay updated on workers’ compensation laws, rules, and regulations.
- Identify cases necessitating large loss and/or reinsurance reports, ensuring comprehensive management.
- Conduct thorough file reviews at various stages of the claims process.
- Contribute to the training of workers’ compensation claim staff under the guidance of management.
- Serve as a technical expert and offer support to management.
- Monitor litigated files to ensure adherence to litigation management protocols.
- Utilize Insurance Service Office (ISO) decision net and claim search inquiries.
- Respond to complaint calls and other inquiries, excluding those related to Department of Insurance (DOI) complaints, with professionalism and efficiency.
- Performs other duties as assigned.
Requirements
- Bachelor's degree or equivalent combination of education and/or experience in the insurance field
- Five or more years of workers’ compensation experience including complex case processing
- Licensed in multiple jurisdictions with a professional claims designation
- Knowledge of applicable state laws across territories of operation
- Knowledge of claims policy, procedures, fiduciary guidelines and best practices
- Skill in interpersonal interactions, with the ability to collaborate effectively with individuals at all organizational levels and with external stakeholders; skill in customer service, problem-solving time management and conflict resolution
- Capacity to work autonomously while ensuring transparent communication with internal leadership
- Skill in planning, time and organizational management; ability to multi-task effectively while paying attention to detail
- Proficient in both verbal and written communication with the ability and commitment to maintain confidentiality
- Proficient with Microsoft Office Suite and function specific software applications
Benefits
- Competitive Salary
- Bonus Structure
- Profit Sharing
- Medical, Dental, Vision Insurance
- Employer Paid Short Term Disability
- Employer Paid Long Term Disability
- Employer Paid Life Insurance
- Voluntary Life Insurance
- 401K with Company Match
- PTO
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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