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Claims Adjuster- Texas Non-Subscriber

3 months ago

Lewisville, Texas, United States Method Insurance Services Full time
Who We Are

Method Workers' Compensation is a portfolio of workers' comp companies with the same mission: minimizing the human and financial cost of workplace injuries. We mitigate workplace injuries and deliver exceptional healthcare outcomes for injured workers, expediting a return to work, preserving families' livelihoods, and enhancing employers' productivity. We maintain in-house expertise in claims management, medical bill review, underwriting, and loss prevention for high-hazard, high-mod, and mid-market risks. From submission to claim, we're there every step of the way, improving outcomes for everyone involved. Method currently operates in all states.

What To Expect

The Claims Adjuster is responsible for investigating, analyzing and evaluating claims to determine if the benefits due are consistent with a client's Work Injury Benefit Plan and/or potential employer's liability claims. Additionally, the Claims Adjuster is to identify if there is a subrogation potential and negotiate settlements to ensure ongoing adjudication of claims within service expectations, industry, and company best practices. This is a full-time, salaried exempt position with standard business hours of Monday through Friday from 8:00am to 5:00pm, with some flexibility at manager's discretion.

What You'll Do
  • Review and understand assigned client Work Injury Benefit Plans.
  • Promptly investigates, evaluates, and manages claim compensability determination and recovery.
  • Manages the medical and return to work process throughout the life of the claim.
  • Evaluate severity of claims by review of medical records to develop and calculate appropriate reserves and manage reserve adequacy throughout the life of the claim.
  • Adhere to Method Best Practices and Claims Protocol.
  • Ensure appropriate claim file documentation and claim coding is complete and accurate.
  • Communicate claim activity regularly to any relevant internal and external stakeholders, including injured worker, policy holder, medical provider, and legal counsel if appropriate.
  • Prepares timely state filings within the state statutory regulations.
  • Calculate the average weekly wage and indemnity benefits owed as well as approve medical and expense payments. Ensure all benefits are paid timely.
  • Ensure timely and cost-effective claims resolution; negotiate settlement of claims within adjusters assigned authority when appropriate.
  • Manage the litigation process and work with legal counsel when necessary.
  • Coordinate vendor utilization while considering claim cost containment techniques and outcomes.
  • Manage claim recoveries to include but not limited to subrogation, and Medicare offsets including but not limited to nurse case management, surveillance, etc.
  • Notify management of large loss, denial, coverage disputes, subrogation potential or other matters requiring escalation or collaboration
  • Perform other duties as requested and assigned.
Requirements

What You Need
  • In-depth knowledge of insurance workers' compensation or non-subscription principles and laws, recovery, off-sets, deductibles, cost containment principles including medical management, Social Security and Medicare application procedures
  • Excellent customer services
  • Excellent judgment, troubleshooting, and problem-solving skills
  • Excellent written and verbal communication skills
  • Detailed oriented with the ability to handle multiple priorities simultaneously while meeting deadlines
  • Excellent collaboration skills working in a team environment
  • Proficient in Microsoft Office Suite, G Suite, or similar software
  • At least five years of experience working with at least one of WC, Non-Subscription or Long-Term Disability claims
  • A combination of education and experience may be accepted
  • Texas adjuster's license required
Preferred Experience

A bachelor's degree from an accredited college or university

What We Offer:

In exchange for your time and expertise, we offer competitive compensation, 401(k) plus matching, health benefits (including HSA Contribution), paid disability, paid parental leave, professional development opportunities, and a hybrid/remote work environment. This is an opportunity to play a key role in the continued success of a growing organization.

Unless fully remote, this position operates in a professional office setting and routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. This is largely a sedentary role with prolonged periods of sitting at a desk and working on a computer. However, some filing is necessary and may require the ability to lift files, open filing cabinets and bend or stand on a stool as necessary.

Method Workers' Compensation is an equal opportunity employer regardless of race, color, gender, age, sexual orientation, gender identity, gender expression, religious beliefs, marital status, genetic information, national origin, disability, protected veteran status, or any other basis protected by federal, state, or local law.