Medical Claims Adjuster/ Processor

3+ years of Workers’ Compensation Lost Time Claim Examiner or Commensurate Experience (Having experience in worker’s compensation is not a requirement but a nice thing to have, as long as the skills they do have are transferable.) Handles all aspects of workers’ compensation lost time claims from set-up to case closure ensuring strong customer relations are maintained throughout the process. - Reviews claim and policy information to provide background for investigation. - Conducts 3-part ongoing investigations, obtaining facts and taking statements as necessary, with insured, claimant and medical providers. - Evaluates the facts gathered through the investigation to determine compensability of the claim. - Informs insureds, claimants and attorneys of claim denials when applicable. - Prepares reports on investigation, settlements, denials of claims and evaluations of involved parties, etc. - Timely administration of statutory medical and indemnity benefits throughout the life of the claim. - Sets reserves within authority limits for medical, indemnity and expenses and recommends reserve changes to Team Leader throughout the life of the claim. - Reviews the claim status at regular intervals and makes recommendations to Team Leader to discuss problems and remedial actions to resolve them. - Works with attorneys to manage hearings and litigation - Controls and directs vendors, nurse case managers, telephonic cases managers and rehabilitation managers on medical management and return to work initiatives. - Complies with customer service requests including Special Claims Handling procedures, file status notes and claim reviews. - Files workers’ compensation forms and electronic data with states to ensure compliance with statutory regulations. - Refers appropriate claims to subrogation and secures necessary information to ensure that recovery opportunities are maximized. - Works with in-house Technical Assistants, Special Investigators, Nurse Consultants, Telephonic Case Managers as well as Team Supervisors to exceed customer's expectations for exceptional claims handling service. Lost Time Claim Examiner position with prior experience in workers’ compensation as a medical only examiner, or commensurate examiner experience in paralegal, short-term / long-term disability, auto personal injury protection / medical injury, general liability or as a claim technical assistant for lost time claims. - Ability to incorporate data analytics and modeling into daily activities to expedite fair and equitable resolution of claims and claim issues. - Exceptional customer service and focus. - Demonstrates a commitment to a career in claims. - Use analytical skills to find mutually beneficial solutions to claim and customer issues. - Ability to prepare and make exceptional presentations to internal and external customers. - Conscientious about the quality and professionalism of work product and relationships with co-workers and clients. - Willing to take ownership and tackle obstacles to meet the company's quality standards for service, investigation, reserving, inventory management, teamwork, and diversity appreciation. - Experience working in a customer focused, fast-paced, fluid environment - Prior workers’ compensation claim handling experience is a plus but not required - Familiarity with claim handling (healthcare, short-term / long-term disability, auto personal injury protection / medical injury, or general liability) is a plus but not required - Prior insurance, legal or corporate business experience is a plus but not required - Proficiency with Microsoft Office Products - Knowledge of medical terminology is a plus but not required - Claim Adjuster licenses in Connecticut, New Hampshire, Rhode Island and Vermont, are necessary; If you do not already have one, you will be required to obtain an applicable resident or designated home state adjusters license and possibly additional state licensure"