Claims Adjuster - Workers Compensation

Job DescriptionJob Description

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.

• Supports the organization's quality program(s).

• Travels as required.

QUALIFICATIONS

• Bachelor's degree from an accredited college or university preferred.

• SIP is preferred not mandatory.

• Min 3 Years of CA claims handling experience required.

• 4 years of claims management experience or equivalent combination of education and experience required.

• Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business.

• Excellent oral and written communication, including presentation skills

• PC literate, including Microsoft Office products

• Analytical and interpretive skills

• Strong organizational skills

• Good interpersonal skills

• Excellent negotiation skills

• Ability to work in a team environment

• Ability to meet or exceed Service Expectations

• 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

• Remote in CA preferred. If candidate is from other state, 3 years of CA Claims handling experience is must.

Location: Orange, CA, US

Posted Date: 11/1/2024