Workers Comp Claims Adjuster

DUTIES AND RESPONSIBILITIES

• Verify coverage of assigned claims and oversee the accuracy of claim set-up
• Ensure timely communication to insureds and claimants with prompt response time to phone calls and emails
• Investigate new and existing workers' compensation claims to determine compensability of claims (in whole and in part) and entitlement to indemnity and medical benefits
• Ensure timely payments of claim bills (medical, legal, vendor) and indemnity payments
• Establish a thoughtful approach to mitigate exposure with recommendations to management
• Effectuate timely offers and settlements and ensure timely file closure
• Ensure accurate and updated file information
• Complete timely reports and file diaries
• Visit assigned insureds periodically. Attend insured meetings and file reviews with insureds
• Obtain medical reports and employer investigation documents. Secure statements from claimants/witnesses
• Review and Approve/Deny timely, requests for authorization of medication and medical procedures/supplies
• Schedule IME’s and SMO’s
• Monitor incoming medical/legal reports and respond accordingly
• Timely and accurately address reserves based upon the exposure
• Submit recommendations to the Claims Branch Manager on cases exceeding personal settlement/reserve authority
• Assign defense counsel upon the approval of the branch manager or VP - Claims.
• Manage defense counsel and work collaboratively regarding strategy on litigated claims, making sure litigation management and billing guidelines are followed
• Obtain expert opinions as needed
• Attend Benefit Review Conferences and Contested Case Hearings required conferences and hearings with defense counsel
• Obtain Jury/Appeal Bonds from Surety when needed
• Monitor vendor participation (e.g. case management, vocational rehabilitation, private investigators) and apply gained knowledge/results appropriately
• Responsible for completing timely and accurate PLN jurisdictional forms and EDI transmittals to the division-applicable governmental agency
• Investigate and report to appropriate jurisdictions claims involving suspected fraudulent claims
• Pursue all viable avenues of subrogation
• Ensure Medicare Section 111 compliance filings and compliance with MSP requirements
• Obtain required credit hours to maintain adjuster licensing
• Ensure updated knowledge/application of DWC jurisdictional rules and regulations
• Mentor, assist, share experience/expertise
• Assist the Branch Manager as needed
• Other duties as assigned/ required

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

REQUIRED SKILLS

• Excellent communication skills with management, employees, and outsiders.
• Excellent computer skills with knowledge of Microsoft Office Suite or similar software.
• Ability to work independently with minimum supervision.