Workers' Compensation Claims Adjuster I

📋 Description

• Conducts independent investigations, evaluations, negotiations, and resolutions of workers’ compensation claims within established authority guidelines; engages with insureds, agents, and partners regarding coverage, status, and inquiries.

• Assesses and evaluates claims, confirming coverage, jurisdiction, and compensability.

• Initiates prompt communication with insureds, claimants, and relevant parties to clarify the claims process.

• Collects statements, documentation, and official reports; meticulously records all file activities and updates claim records.

• Establishes and modifies reserves in accordance with company policies.

• Reviews medical treatments, billing, and wage data to determine suitable benefits and payments.

• Coordinates medical care and return-to-work initiatives.

• Identifies and actively seeks subrogation and recovery opportunities.

• Ensures timely statutory notifications and adherence to jurisdictional requirements.

• Monitors claim progression and escalates complex claims as necessary.

• Prepares evaluations for settlements, strategies, and negotiation objectives.

• Investigates and addresses compensability and coverage concerns.

• Negotiates settlements and collaborates with attorneys; participates in mediations and conferences as required.

• Issues settlement documentation and payments within authority limits.

• Provides clear and timely updates on claim status to insureds, agents, and claimants.

• Ensures compliance with all state reporting and documentation regulations.

• Collaborates with internal teams (SIU, Subrogation, Medical, etc.) and offers support to team members.

• Submits referrals and promotes initiatives such as return-to-work programs and preferred provider networks.

• Assists with account servicing and marketing efforts as needed.

• Maintains requisite licenses/CEUs and engages in ongoing training on regulatory and medical updates.

⛳️ Requirements

• Bachelor’s degree or equivalent relevant experience.

• At least one year of experience in workers’ compensation claims adjusting or a related field.

• Must obtain all applicable state licenses within one year of hire.

• Relevant insurance designations are preferred.

• Possesses a working understanding of the theory and practice of claims functions.

• Good knowledge of insurance contracts, medical terminology, and substantive and procedural laws.

• Ability to maintain high standards of professional conduct and adhere to a code of ethics.

• Strong proficiency in computers and claims systems.

• Excellent organizational, written, and verbal communication skills.

• Effective investigative and problem-solving skills.

• Occasional travel is required; a valid driver's license with an acceptable motor vehicle report as per company standards is necessary if driving.

🏝️ Benefits

• Exceptional benefits package, including life, medical, dental, vision, and prescription drug coverage.

• Competitive paid time off policy and an annual full day of volunteer time off.

• Financial incentives, such as a 401(k) plan match, pension plan, OneEMC bonus plan, and recognition and anniversary awards.

• Opportunities for professional development and growth, including tuition reimbursement.

• Wellness initiatives aimed at enhancing team member well-being and lowering health insurance costs.

• Flexibility in dress code and opportunities for alternative work arrangements.