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Claims Adjuster

1 month ago

Sacramento, United States NESCO Inc Full time

Primary Purpose:
To analyze mid- and higher-level workers compensation claims to determine benefits due, ensure ongoing adjudication of claims within company standards and industry best practices, identify subrogation opportunities, and negotiate settlements.

Essential Functions and Responsibilities:

  • Manage workers compensation claims, determine compensability and benefits due on long-term indemnity claims, monitor reserve accuracy, and file necessary documentation with state agencies.
  • Develop and manage action plans for resolving workers compensation claims, coordinate return-to-work efforts, and approve claim payments.
  • Approve and process assigned claims, determine benefits due, and manage action plans pursuant to the claim or client contract.
  • Manage subrogation of claims and negotiate settlements.
  • Communicate claim actions with claimants and clients.
  • Ensure claim files are properly documented and claims coding is correct.
  • Process complex lifetime medical and/or defined period medical claims, including state and physician filings and decisions on appropriate treatments recommended by utilization review.
  • Maintain professional client relationships.
  • Perform other duties as assigned and support the organizations quality programs.
  • Travel as required.

Qualifications:

Education & Licensing:

  • Bachelors degree from an accredited college or university preferred.

Experience:

  • Four (4) years of claims management experience or an equivalent combination of education and experience required.
  • Minimum 3 years as indemnity examiner handling CA Claims WC experience required.
  • Prior public entity experience preferred.

Skills & Knowledge:

  • Working knowledge of regulations, offsets and deductions, disability duration, medical management practices, and Social Security and Medicare application procedures as applicable to the line of business.
  • Excellent oral and written communication, including presentation skills.
  • Proficiency in Microsoft Office products.
  • Strong analytical and interpretive skills.
  • Excellent organizational skills.
  • Good interpersonal skills.
  • Excellent negotiation skills.
  • Ability to work in a team environment.
  • Ability to meet or exceed service expectations.

Work Environment:

  • Consideration will be given to reasonable accommodations when applicable and appropriate.

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 and travel as required.

Auditory/Visual:

  • Hearing, vision, and talking.

Note:

  • Credit security clearance, confirmed via a background credit check, is required for this position.

Nesco Resource provides equal employment opportunities to all employees and applicants 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.