Senior Workers Compensation Claims Adjuster (Temporary)

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:

  • Coverage:
    • 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.
  • Subrogation:
    • Refer all files identified with subrogation potential to the subrogation department.
  • Investigation:
    • 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.
  • Reserves:
    • 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.
  • Resolution:
    • 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.

Qualification Requirements:

  • 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.
  • Abilities:
    • 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).

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