WC Claims Adjuster III

Claims Adjuster III is responsible for investigations, adjustments, negotiations and trial preparation arising under specific business policies and procedures.

ESSENTIAL JOB DUTIES

• Investigate claims to determine compensability and discuss escalated claims with supervisor
• Provide quality customer service to all parties of the claim; deliver appropriate benefits promptly and efficiently
• Review bills, determine action and process accordingly; facilitate cost effective claims resolution
• Determine necessity for independent medical evaluations, second opinions, nurse and physician reviews and refer when appropriate
• Determine necessity for referral to outside services to include surveillance, field adjusters or field case managers
• Document claims activity in diary notes; review and maintain current diary on all open claims
• Adequately reserve all claims; complete reserve and settlement evaluations
• Recognize and pursue cases with subrogation or indemnification potential
• Administrate litigation process
• Accurately file all state forms in a timely manner
• Prepare reporting as required for large loss or reinsurance carrier
• Attend continuing training programs in workers’ compensation laws, rules and regulations
• Ensure mail is processed daily
• Ability to adhere to attendance guidelines
• Additional duties and projects as assigned

ESSENTIAL JOB REQUIREMENTS, EDUCATION and WORK EXPERIENCE

• Bachelor's degree from an accredited college or university; or equivalent education and experience in Insurance or other related field
• 10 or more years’ experience adjudicating claims in the assigned area of business
• Knowledge of applicable laws, rules and regulations pertinent to the area of business assigned (i.e. knowledge of Worker’s Compensation laws for an employee assigned to process Lost Time claims under Worker’s Compensation policies)
• Proficient decision making skills
• Strong negotiation skills
• Successfully completes relevant company-sponsored continuing education as recommended by Claims Department management
• Knowledge of technical adjudication process
• Knowledge of legal statutes for applicable jurisdictions
• Knowledge and understanding of contracts and reinsurer agreements
• Understand and adhere to fiduciary guidelines
• Self-motivated and flexible with ability to work independently
• Demonstrated proficiency in interviewing, problem solving, communication, time management, and conflict resolution skills
• Ability to travel as required
• Strong customer service, problem solving, interpersonal and organizational skills
• Strong verbal and written communication skills
• Ability to learn new software systems and programs
• Ability to multi-task and focus on detail
• Ability to maintain the highest level of confidentiality
• Ability to positively interact with internal and external customers
• Computer literate; advanced Microsoft Office skills

NORMAL WORK ENVIRONMENT & PHYSICAL EXPECTATIONS

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• General office environment
• General sedentary work; employee will be able to sit for extended periods of time and work in front of a computer or on a telephone
• May lift up to 20 pounds

NOTE: The information listed above is not intended to be construed as an employment contract, nor is it intended to state or imply an exhaustive list of duties to be performed by this employee or by this job title. Every employee at every level of the company is expected to perform additional duties or tasks as required by business need and requested by their Supervisor/Manager.

demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.