Workers’ Compensation Claims Specialist II – Lost Time Adjus...

PGCS, Inc., a subsidiary of Brown & Brown, Inc., is seeking a Workers’ Compensation Claims Specialist II / Lost Time Adjuster. They will be responsible for investigation, evaluation, disposition and settlement of Workers’ Compensation claims for self-insured and public entity accounts, including complex and high exposure claims, with minimal supervision. This includes the investigation, determination and evaluation of coverage, liability and damages, and the setting of proper reserves. Requires independent decision making and a high level of discretion and judgment in claim handling functions on behalf of clients for claims service business operations, ensuring excellent customer relationships and quality customer service. Opportunity to work remotely for the right candidate.

Essential Duties:

• Analyze the claim exposure to determine the proper course of action and to appropriately settle or close the claim in accordance with state, company and client policy and procedure.
• Build and maintain rapport with client contacts to ensure retention; perform in manner to meet/exceed client expectations, following policy and procedure per client.
• Manage and direct the claim file including determination of indemnity, calculate loss of income; whether medical is related and appropriate; evaluate treatment plan, testing, surgery, surveillance, attorney involvement, return-to-work, light duty; appropriate calculation and timely payment of all benefits.
• Handle legal aspects of the file in negotiation of settlement; develop litigation/defense strategies with attorneys assigned to the claim file. Handle depositions, mediations and hearings.
• Evaluate files for reserve potential and for settlement (effective knowledge of MSAs and structured annuities).
• Document and communicate all claim activity timely and effectively and in a manner which supports the outcome of the claim file; develop and maintain a progressive plan of action.
• Interact extensively with various parties involved in the claim process.
• Manage EDI requirements per state and company protocol in a timely and appropriate manner.
• Identify and pursue SDF, subrogation, fraud, vocational/field case management involvement, as necessary.
• Comply with excess carriers’ limits and reporting requirements.
• Properly handle status reports/claim reviews with clients; travel as required.
• Maintain current knowledge of law and statute, maintain CEUs and license in current status related to state in which handling claims.
• Perform other duties as assigned.

• A minimum of three years of Florida claims-related experience with a consistent high level of performance and achievement.
• Experience in a claims environment handling lost time claims including litigated files.
• Extensive knowledge of accepted industry standards and practices including case law. Ability to successfully negotiate the settlement and disposition of claims, including the ability to interpret related documentation.
• Active Adjuster license (FL 5-24, 5-20 or 6-20) required.

• Ability to effectively operate a personal computer and related claims and business software. Familiarity with “paperless” work environment helpful.

• Good communication skills, both oral and written; good customer service skills.
• Assertive self-starter with excellent organizational skills. Team player. Good attendance.
• Ability to work accurately in a fast-paced position ensuring all policies and procedures are managed to expected timeframes.

Re-certified Great Place to Work® 2021-2022. Long-term, stable company with great reputation and excellent work environment, great teammates and wonderful team spirit. Top notch benefits including medical, dental, STD, LTD, life, Employee Stock Purchase Plan, 401-k with company match – eligible 1st of month after 30 days. Five weeks average Paid Time Off/year, floating holiday, regular holidays.

Competitive, based on experience.

Team Resources Department at hr@usis-tpa.com