Claims Adjuster - Workers Compensation

Description

• To analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.
• Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
• Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
• Manages subrogation of claims and negotiates settlements.
• Communicates claim action with claimant and client.
• Ensures claim files are properly documented and claims coding is correct.
• May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
• Maintains professional client relationships.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Lost Time Claim Management
• End-to-end handling of indemnity claims, including initial investigation, compensability determination, and ongoing management.
• Reserving claims for ultimate exposure
• Handling caseload of diaries, correspondence (including email and faxed documentation.)
• Jurisdictional Knowledge
• In-depth understanding of PA and NJ workers' compensation statutes, regulations, and case law.
• Familiarity with state-specific forms (e.g., LIBC forms for PA, WC forms for NJ).
• EDI filing and clearing of errors.
• Wage Loss & Benefit Calculation
• Accurate calculation of Average Weekly Wage (AWW) and Temporary Total Disability (TTD) benefits.
• Application of PA's 7-day waiting period and NJ's 7-day retroactive rules.
• Medical Management
• Coordination of treatment plans, utilization review, and compliance with state medical fee schedules.
• Familiarity with NJ's authorized provider rules and PA's panel provider requirements.
• Litigation Handling
• Managing claims in litigation, including working with defense counsel, attending hearings, and preparing testimony.
• Understanding of PA's Supersedeas process and NJ's informal/formal hearing procedures.
• Return-to-Work Coordination
• Developing modified duty programs and collaborating with employers to facilitate early return-to-work.
• Communication & Documentation
• Stakeholder Communication
• Regular interaction with injured workers, employers, medical providers, and attorneys.
• Clear and timely documentation of all claim activities.
• Superior customer service and phone etiquette
• Negotiation & Settlement
• Experience negotiating lump-sum settlements and Section 32 agreements (NJ) or Compromise & Release (PA).
• Drafting settlement evaluations and experience working with Medicare requirements
  
  

Qualifications

• MUST HAVE 5 years' experience directly managing lost time claims in both NJ and PA any other states are beneficial.
• License are preferred, but not required
  
  

Benefits

Healthcare Insurance: Synectics offers eligible employees and their dependents healthcare coverage through BlueCross BlueShield of Illinois. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics. Premiums are subsidized by Synectics.

Dental Insurance: Synectics offers eligible employees and their dependents a dental plan through MetLife. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics.

Vision Insurance: Synectics offers eligible employees vision insurance through VSP. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full time employment with Synectics.401(k) Plan: The Synectics Inc. Investment Savings Retirement Plan. Synectics offers all employees who are 21 years of age or older the opportunity to invest in the 401(k) Plan on the first enrollment date that is at least 30 days after employment begins. Enrollment dates are each January 1st, April 1st, July 1st, and October 1st.

Technical Certification Bonus: Synectics is pleased to award its employees a bonus of up to $500 for an approved professional certification. In determining the bonus amount, Synectics will consider the cost of the test(s) for any certification relating to your current position, achieved during your employment with us. Only one Certification Bonus per calendar year may be awarded per employee. Only current, active employees will be eligible to receive this bonus. It will be awarded 90 days after the Synectics office has received documentation confirming the successful completion of the certification.

Synectics is an equal opportunity employer.