Workers' Compensation Claims Adjuster I

This is a fully remote position, open to applicants in Texas.

📋 Description

• Oversee a caseload of medical-only workers’ compensation claims with close supervision.

• Conduct three-point communication involving the injured worker, employer, and treating physician to initiate claims and collect relevant information.

• Investigate claims, determine compensability, assess the mechanism of injury, and identify benefits.

• Refer questionable AOE/COE claims for SIU review when necessary.

• Ensure accurate claim documentation and maintain classification of claims as medical-only.

• Guide medical care throughout the lifecycle of the claim.

• Challenge unnecessary or unreasonable treatments.

• Collaborate with utilization review and medical bill review teams and follow up on their decisions.

• Track the injured workers’ progress toward maximum medical improvement and coordinate return-to-work plans.

• Identify claims that may escalate to indemnity status and flag them for supervisory assessment.

• Set initial reserves and periodically monitor and adjust these reserves.

• Prepare and submit 90-day carrier status reports in line with client and regulatory standards.

• Negotiate and conclude claim settlements, including resolving liens.

• Identify and manage subrogation opportunities alongside recovery specialists.

⛳️ Requirements

• 1–3 years of experience as a WC Claims Assistant, Trainee, or Future Med Adjuster; OR a Bachelor’s degree with a minimum of six months of WC claims experience.

• An active Texas Worker's Comp or all-lines license is required; multi-state licensing is preferred.

• Designations such as AIC, ARM, SIP, or WCCP are advantageous but not mandatory.

• Preference for familiarity with claims management platforms (e.g., Guidewire, Juris, ClaimCenter).

• Working knowledge of Texas WC regulations.

• Proficiency in the Microsoft Office Suite.

• Ability to read and understand medical records.

• Capability to conduct three-point communication with the injured worker, employer, and treating physician.

• Competence in assessing compensability and evaluating the mechanism of injury.

• Ability to make benefit determinations in accordance with applicable state WC regulations.

• Skill in maintaining accurate claim documentation and classifying claims as medical-only.

• Ability to manage medical care and coordinate utilization review and medical bill review.

• Capacity to monitor progress towards maximum medical improvement and facilitate return-to-work outcomes.

• Proficiency in establishing, monitoring, and adjusting reserves.

• Ability to submit 90-day carrier status reports.

• Skill in negotiating and finalizing claim settlements, including lien resolution.

• Ability to identify and manage subrogation opportunities.

• Reasonable accommodations may be provided to enable individuals with disabilities to perform the essential functions of this position.

🏝️ Benefits

• Comprehensive medical, dental, and vision coverage.

• Company contributions to HSA and FSA plans.

• Employer-paid life and disability insurance.

• 401(k) plan with company matching.

• Paid time off (PTO) and company-paid holidays.

• Learning and development opportunities that encourage genuine career advancement.

• Access to employee assistance resources.

• A supportive culture that prioritizes balance and wellbeing.

• Experienced mentors and clear guidance.

• Manageable caseloads.

• Collaborative teams and expert support.

• Realistic career paths for professionals aiming for growth or leadership roles.