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Workers Comp Claims Adjuster
3 months ago
**DUTIES AND RESPONSIBILITIES**
- Verify coverage of assigned claims and oversee the accuracy of claim set-up
- 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
- 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
- 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.
