The 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 other jurisdictions, handle multiple programs/clients, and will be required to obtain licensing in all states requiring licensing after hire. Candidates will be handling claims in multiple states.
Must have 3 to 5 years of overall claims experience handling 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 150 pending 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, the 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 necessary. 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 before the mediation date and negotiate a settlement.
- Evaluate and negotiate liens.
- Recognize and report potential fraud cases.
- Litigation Management:
- 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 promptly completed. Litigated files must be diaried effectively based on current activity, but no greater than every 60 days.
- Review claim files involving active litigation every month 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 (the anticipated cost to bring a 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 timeframes.
- Reporting Requirements:
- 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 the closing ratio as dictated by the management team.
- Education / Licensing:
- High School Diploma, college degree preferred.
- Must have 7 to 10 years of overall claims experience, preferably in the line of business being handled.
- Must have 7+ years of substantial litigation experience for all other lines except workers’ compensation.
- Must have 5+ years Construction Defect or similar/related experience if handling that line of business.
- Must be eligible for reserve/payment authority level of $50,000+ when appropriate
- Must possess, or have the ability to obtain, a Florida Adjuster’s license or other required jurisdictional licensing.
- Technical skills:
- 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 extended 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).