Claims Adjuster- California Workers' Compensation

6 days ago

Lewisville, United States Method Workers Compensation LLC Full time
Job DescriptionJob DescriptionDescription:

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 primarily responsible for analyzing workers' compensation claims to determine the benefits due. This role is also responsible for ensuring the ongoing adjudication of claims within service expectations and company best practices pursuant to all state, legal, statutory, and regulatory bodies. 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

  • With minimal supervision, investigate claims, including but not limited to reviewing the first report of injuries, medical records; contracts; contacting insureds, injured workers, medical providers, and other parties to determine compensability in a timely manner.
  • Understands, analyzes, and applies policy components to evaluate coverage.
  • Ensure compliance of claims handling requirements pursuant to all state, legal, statutory and regulatory bodies.
  • Exercise discretion and independent judgment with respect to evaluating and managing claims, including determining reserve amounts and document rationale.
  • Evaluate exposure of claims by reviewing medical records and claim facts to determine causal relatedness of medical conditions.
  • Manage the medical treatment and return to work process throughout the life of the claim.
  • Adhere to Method Best Practices, Method Claims Protocol, and Claims Handling Guidelines.
  • Maintain appropriate claim file documentation and accurate claim coding.
  • Communicate claim activity regularly to any relevant internal and external stakeholders, including injured workers, policyholders, medical providers, and carriers, when appropriate.
  • Timely prepare state filings within the state statutory regulations.
  • Calculate the average weekly wage and indemnity benefits owed.
  • Ensure all benefits are paid timely and in accordance with jurisdictional requirements.
  • Exercise accurate discernment and decision-making to analyze claims exposure and to plan and document the proper course of action to move the claim to resolution.
  • Coordinate vendor utilization while considering claim cost containment techniques and outcomes, including but not limited to nurse case management, surveillance, etc.
  • Manage claim recoveries, including but not limited to Second Injury Fund, subrogation, and Medicare offsets.
  • Notify management of large loss exposure, denial, coverage disputes, subrogation potential, or other matters requiring escalation or collaboration.
  • Maintain knowledge of jurisdictional requirements and applicable case law for each State, including appropriate licensure and continuing education requirements.
  • Perform other duties as requested and assigned.
Requirements:

What You Need

  • In-depth knowledge of workers' compensation insurance principles and laws, as well as cost containment principles
  • Strong analytical, critical thinking, and problem-solving skills
  • Detail-oriented with the ability to work in a team environment
  • Excellent customer service, written and verbal communication skills
  • Ability to prioritize and balance multiple projects simultaneously
  • Results-driven, proactive, and able to work autonomously
  • Ability to exercise discretion and independent judgment
  • Proficient in Microsoft Office Suite, PDF Professional, G Suite, or similar software.
  • A combination of education and experience in a TPA or brokerage environment will be considered
  • State adjuster’s licenses as required


Preferred Experience

  • At least 1-4 years of experience in workers’ compensation claims experience is preferred
  • Bachelor’s degree from an accredited college or university
  • Bilingual in Spanish preferred.


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.

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