he candidate must have a valid license for their state of domicile if that state requires a license. Valid licenses in additional jurisdictions preferred. Candidate must be willing to learn additional jurisdictions and will be required to obtain licensing in all states requiring licensing after hire. Candidates will be handling claims in multiple states. Jurisdictional knowledge in FL, GA, MO, OK, TX and or WV.
Must have 3 to 5 years of overall claims experience handling medical only workers compensation claims.
Must be eligible for reserve/payment authority level of $50,000+ when appropriate.
Must possess required Adjuster’s license(s) with the ability to obtain other required jurisdictional licensing.
The candidate will handle a caseload of approximately 175 pending medical only claims encompassing all levels of complexity. Requires establishing facts of loss, coverage analysis, investigation, compensability/liability/negligence determination, coordination of medical care, litigation management, damage assessment, settlement negotiations, identifying potential fraud & appropriate use of authorized vendors. Includes timely & appropriate reserve analysis & report completion. Ability to attend conferences, client meetings, mentor other adjusters & assist management as requested. File handling must be within state statutes, Client Claims Handling Guidelines & NARS Best Practices.
Essential Duties and Responsibilities:
- Identify, analyze and confirm coverage.
- Customer Service/Contact:
- Contact appropriate parties and providers to determine liability, compensability, negligence and subrogation potential.
- Contact appropriate parties to obtain any needed information and explain benefits as appropriate. Continue contact throughout the life of the file as appropriate.
- Answer phones, check voice mail regularly, and return calls as needed.
- Assist with training/mentoring of Claims Adjusters.
- Assist management when required with projects or leadership as requested.
- Handle the various duties/responsibilities of the Assistant Unit Manager/Unit Manager as delegated in their absence.
- Must be willing and able to attend meetings by Skype or Facetime as requested.
- Refer all files identified with subrogation potential to the subrogation department.
- Verify facts of loss and pertinent claims facts such as employment, wages, or damages and establish disability with treating physicians as appropriate.
- Identify cases for settlement. Evaluate claims and request authority no later than 30 days prior to mediation date and negotiate settlement.
- Evaluate and negotiate liens.
- Recognize and report potential fraud cases.
- Develop and direct a litigation plan with defense attorney (if assigned), utilizing all defenses and tools to bring the file to closure. Ensure all filings and state mandated forms are completed timely. Litigated files must be diaried effectively based on current activity, but no greater than every 60 days.
- Review claim files involving active litigation on a monthly basis at minimum, and document responses to filings, development of defenses, depositions, and timely referral to defense counsel.
- Direct the actions of defense counsel on litigated files.
- Attend mediations and trials as required for cost effective litigation management.
- Establish ultimate reserves (anticipated cost to bring file to close based on known facts) as soon as practical and monitor to adjust at the time of any exposure changing event.
- Pay all known benefits, ensuring they are paid timely on state statute.
- Verify all provider bills have been appropriately reviewed and paid within standard time frames.
- Report all serious injuries/liability issues and potential large loss claims to the client and/or reinsurer based upon the criteria provided by the client.
- Must pass all internal and external audits, which include those performed by regulatory agencies, carriers, and clients.
- Follow reporting requests as outlined by client files and NARS guidelines.
- Document plan of action in the claim system and set appropriate diaries.
- Maintain a regular diary for monitoring and directing medical care, case development, or litigation.
- Close all files as appropriate in a timely and complete manner.
- Maintain closing ratio as dictated by management team.
- Advance level of interpersonal skills to handle sensitive and confidential situations and information.
- Requires advanced ability to negotiate claims and to direct litigation.
- Must have negotiation and litigation skills for significant work with attorneys and arbitration on first and third party claims.
- Requires advanced ability to work independently.
- Requires an advanced level of organization and time management skills.
- Must possess advanced level written and verbal communication skills.
- Must be proficient in Microsoft Office applications.
- Must be able to explain and appropriately respond to auditors, clients, and potential clients during in-person presentations.
- Requires long periods of sitting.
- Requires working indoors in environmentally controlled conditions.
- Requires lifting of files and boxes up to approximately 20 pounds.
- Repeated use of a keyboard, mouse, and exposure to computer screens.
- Requires travel as assigned, which can at times be extensive (5 to 7 days per month).