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Claims Adjuster

1 month ago

orange, United States Nesco Resource Full time
PRIMARY PURPOSE:
To analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency. Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments. Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract. Manages subrogation of claims and negotiates settlements. Communicates claim action with claimant and client. Ensures claim files are properly documented and claims coding is correct. May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review. Maintains professional client relationships.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
Performs other duties as assigned. Supports the organization's quality program(s). Travels as required.
QUALIFICATIONS
Education & Licensing Bachelor's degree from an accredited college or university preferred.
Experience
Four (4) years of claims management experience or equivalent combination of education and experience required.
Skills & Knowledge
Working knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure as applicable to line of business Excellent oral and written communication, including presentation skills PC literate, including Microsoft Office products
Analytical and interpretive skills Strong organizational skill Good interpersonal skills
Excellent negotiation skills Ability to work in a team environment Ability to meet or exceed Service Expectations
WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations. Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines Physical: Computer keyboarding, travel as required Auditory/Visual: Hearing, vision and talking NOTE: Credit security clearance, confirmed via a background credit check, is required for this position. The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.
Requirements:Min 3 Years of CA claims handling experience required.
Remote in CA preferred. If candidate is from other state, 3 years of CA Claims handling experience is must.
SIP is preferred not mandatory.
Nesco Resource offers a comprehensive benefits package for our associates, which includes a MEC (Minimum Essential Coverage) plan that encompasses Medical, Vision, Dental, 401K, and EAP (Employee Assistance Program) services.
Nesco Resource provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.