Senior Claims Adjuster | Remote Opportunity

Working in the eastern time zone, preference given to those with workers’ compensation claims experience in the following jurisdictions:  CT, MA, ME, NJ, NY, PA, RI & VT.

Summary:

Perform duties to independently manage a caseload of complex workers’ compensation claims, determine compensability, set reserves, and process payments, within the limits of standard or accepted practice. Analyzes and interprets statutes and regulations applying to case facts to render appropriate legal and ethical decisions. Analyzes legal issues and directs legal strategy. Utilizes independent judgment in decision-making, managing claims in a prompt and thorough manner from inception through closure. Aggressively negotiates settlement of claims. Supports supervisor or manager as needed. Work will be performed under direct supervision within a computer-based environment. Continually increases technical knowledge. #LI-Remote

The ideal candidate will be experienced and/or licensed in the following states: CT, MA, ME, NJ, NY, PA, RI & VT.

Pay Range $65,000 - $85,000 (discussed on first interview)

Essential Functions:

• Responsible for complex, litigated and/or high exposure cases. Receive and review information related to new claims. Communicate with injured workers, employers, and medical providers. Direct or conduct prompt and thorough investigation of case facts and circumstances. Analyzes case facts, applies appropriate statutes and regulations in determine compensability. Understands and adheres to Claims Best Practices.
• Using independent judgment and analysis of cost factors may assign case to contactor for investigation of circumstances when compensability is questionable.
• Accurately calculates and pays appropriate benefits in a timely manner, proactively manages claim costs and expenses.
• Set up file diaries, manage medical treatment, establish reserves up to authority level, submit reserve recommendations of higher level for authorization, and file required State forms. Document follow-up care, actions taken to settle claim and other claim related activity. Has authority to settle claims.
• Independently analyzes case facts to establish timely and accurate case reserves. Requires knowledge of medical disabilities and related costs, as well as judgment of extent of disability. Applies knowledge of medical procedures, disabilities, and likely duration to determine accurate estimate of claim cost.
• Continuously analyzes case facts to identify possible fraud or abuse throughout course of claim.
• Follow up with contacts to medical provider and insured employer regarding injured workers’ progress. Ensures quality case and medical management by applying appropriate medical concepts, and by interpreting and applying appropriate statutes and regulations. Requires a high degree of independent judgment to apply facts of case and render accurate decisions. Support the process by scheduling medical or testing appointments and providing authorizations. Demonstrate sound medical management skills and aggressive claims handling, proactively pursuing return to work.
• Using strong claims management skills independently develops, monitors and adheres to a written plan of action to facilitate ongoing claim management, quick resolution and best possible outcome.
• Proactively manages claim litigation process. Handles legal issues that can be adjudicated without the use of a defense attorney. Directs legal strategy and participates in preparation of case for next level(s) of litigation. Testifies at those levels as required.
• Composes professional letters to insured’s, physicians and employees, as necessary.
• Review and respond to incoming mail, emails, telephone calls and fax transmissions from providers and injured worker, related to caseload. Take actions required to respond within regulations and policy.
• Review and approve or deny medical bills.
• Audits physician reports of permanent partial disability evaluations to ensure accuracy in accordance with the specific jurisdictional guides. Ensures prompt and appropriate processing of permanents partial disability benefits.
• Evaluates, prepares, and presents cases of possible permanent total disability to the appropriate jurisdiction department.
• Evaluates and identifies third party liability.
• Participates with Underwriting Department as needed in agent or insured’s claims staffing.
• Assumes the duties of Co-Adjusters in their absence.
• Provides testimony at hearings as needed.
• Conduct business at all times with the highest standards of personal, professional and ethical conduct.
• Ensures timely compliance with all policy and procedures as well as jurisdictional statutes.
• Ensures timely and independent compliance with management issues; prioritizes and ensures timely completion of activities and assignments.
• Established and maintains ongoing professional communications with all appropriate parties, internal and external, ensuring satisfaction with company services.
• Mentors junior Claims Adjusters.
• Acts as a resource/advisor for the department on the accurate interpretation and application of jurisdictional and regulatory matters, policies, and procedures related to workers’ compensation claims management and provides formal training as needed.
• Maintains professional and technical knowledge by attending employer sponsored training classes.
• Visits employers relative to claims management, as required.
• All other duties as assigned or as situation dictates.
• May fill in for absent supervisor.

Required Minimum Qualifications / Knowledge, Skills & Abilities:

• Superior written and oral communication, listening, interpersonal, customer service and telephone skills
• Proficient in the use and knowledge of MS Office software, with the ability to type at a minimum of 35 wpm.
• Demonstrated knowledge of Workers’ Compensation laws and ability to adhere to statutes, regulations and company policies and practices, as well as related claim management procedures/protocols. Comprehensive knowledge of AMA Guides to the Evaluation of Permanent Impairment and medical terminology. Active California license required.
• Self motivated with the ability to work independently with minimal direction. The ability to multi-task, skills to determine the relative importance of each, adhere to deadlines, and complete assignments accordingly.
• Excellent analytical, problem solving and decision-making skills and ability to deal professionally with people in stressful situations.
• Ability to maintain confidentiality.
• If State Certification is required, must meet certification within state mandated time frame.
• Must have High School Diploma or GED equivalent.
• Minimum of 8 years experience working in a claims environment at the Adjuster level or higher managing exposure lost time claims of a complex nature.
• Ability to participate in job related internal and external training and pass any tests within the set guidelines.

Preferred Qualifications / Knowledge, Skills & Abilities:

• Bachelor’s degree
• AIC, ARM, or CPCU certification, working knowledge of a claims management system.
• Working knowledge of an imaged claims environment.
• Bilingual in English and Spanish.
• Current Experienced Claims Adjuster Designation.

Working Conditions:

• Fully remote position
• Occasionally fluctuations in pace and priority will occur

Physical Demands:

• While performing the duties of this job the employee is regularly required to sit, stand, use hands to finger, handle, or feel; reach with hands and arms and talk or hear.
• Frequently required to lift, push, pull, twist or otherwise handle items of 10- 25 pounds.
• The vision requirements include: close vision, peripheral, depth, far and near sightedness.

As a dynamic, fast-growing provider of workers' compensation insurance and services, we are seeking a goal-oriented individual willing to put their ideas to work!

We offer a positive, challenging work environment, combined with an opportunity to build your career as you help us grow our business, in innovative and imaginative ways that are uniquely EMPLOYERS®!

Headquartered in Reno, Nevada, EMPLOYERS attributes its long-standing success to its most valuable resource, our employees across the United States. EMPLOYERS is known for the quality service and expertise we provide to our clients, and the exemplary work environment we provide for our employees.

We live and breathe our core values: Integrity, Customer Focus, Collaboration, Initiative, Accountability, Innovation, and Personal Fulfillment. These are the pillars that support how we do business with our clients as well as how we treat each other!

At EMPLOYERS, you’ll discover an energetic environment that inspires top achievement. As “America’s small business insurance specialist”, we have the resources, a solid reputation and an expanding nationwide identity to enrich your work/life and enhance your career.