Workers Compensation Claims Adjuster

4 weeks ago

Houston, United States Memorial Hermann Health System Full time

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

**Job Summary**

The Position is responsible for investigating, evaluating and resolving assigned claims in order to achieve the best outcomes. In this position the Claims Adjuster will administer and resolve claims in a timely manner in accordance with legal statues. best practices and company guidelines.

**Minimum Qualifications**

**Education**: Bachelor's degree in business, finance **or** related field; in lieu of degree; four(4) **or **more years of equivalent work experience required in an insurance related industry required

**Licenses/Certifications**:

- Current, unrestricted Associate in Claims (AIC) Designation **or** similar professional designation preferred
- ** and/or **five** (**5) years of experience as a license adjuster;
- Posses current, unrestricted Texas all lines adjuster license

**Experience / Knowledge / Skills**:

- At least three (3) to five (5) years experience handling non-subscription claims in Texas
- Familiarity with medical terminology is required
- Strong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneously
- Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
- Strong verbal, written communication skills and customer service skills gained through previous work experience
- Strong computer literacy, including working knowledge of MS Office Product Suite, i.e. WORD, Excel, PowerPoint
- Ability to travel for business purposes, up to 25% of the time (Houston metro area only)

**Principal Accountabilities**
- Promptly investigate all assigned claims including field investigations with mínimal supervision, including those of a more complex nature
- Determines coverage, compensability, potential for subrogation recovery
- Alerts Management to potentially suspect claims
- Ensures timely denial or payment of benefits in accordance with jurisdictional requirements
- Within granted authority, establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure
- Processes claims settlements within granted authority
- Establishes and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
- Works collaboratively with legal counsel, nurse case manager, return to work manager and other professionals to develop and execute return to work strategies
- Maintains a working knowledge of jurisdictional requirements and applicable case law
- Demonstrates technical proficiency through timely, consistent execution of best claim practices
- Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues.
- Provides a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions.
- Authorizes treatment based on the practiced protocols established by statute or the medical guidelines.
- Communicate, collaborate and cooperate with internal and external stakeholders.
- Adheres to all Compliance/Program Integrity requirements.
- Complies with HIPAA Regulations
- Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
- Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann's service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.
- Other duties as assigned.

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