Remote Workers Compensation Adjuster

Summary

The Claims Adjuster reports to the unit Claims Supervisor and manages an assigned inventory of claim files, including cases of extreme complexity or with unique issues. Key responsibilities include performing a three-point contact on all new losses, documenting case facts, forming a partnership with the medical case manager, pursuing subrogation, and assuring compliance with applicable statutes and service contracts.

Requirements

• Requires a working knowledge of the Labor Code of the State of California as it pertains to workers compensation claims and the legal requirements for handling them
• Litigation management - Direct, manage, and control the litigation process
• Bachelor's degree from four-year college or university; at least seven years related experience and/or training; or equivalent combination of education and experience. Requires a high degree of claims handling expertise to include a minimum of at least five years experience managing indemnity cases, many with complex or high potential subrogation, rehabilitation, medical management, and/or legal issues & possess an SIP certificate
• Active study for the IEA Certificate and Self-Insured Certificate, and successful completion of, or active study for the WCCP designation, or the equivalent in related studies or work experience

Responsibilities

• Perform a three-point contact on all new losses within 24 hours of receipt of the claim
• Thoroughly and accurately document ongoing case facts and relevant information necessary for establishing compensability, the need for disability payments, the use of vendors, medical and expense payments, and what is being done to move the case toward closure
• Assure that all assigned indemnity claims have an up-to-date plan of action outlining activities and actions anticipated for ultimately resolving the claim
• Form a partnership with the medical case manager to maximize early return to work potential
• Initiate the referral to the SIU of cases with suspected fraud
• Aggressively pursue subrogation from culpable third parties, contributions on multiple defendant cases, and apportionment when there is pre-existing disability
• Assure that the claim file is handled totally in accordance with applicable statutes as well as in-force service contracts and company guidelines
• Review and approve all vocational rehabilitation plans
• Establish, monitor, and adjust monetary case reserves when warranted and in strict accordance with assigned authority levels
• Review all medical bills for appropriateness prior to referral to InterMed for payment and posting to the claim file
• Exhibit and maintain a courteous and helpful attitude and project a professional image on behalf of the company
• Respond to telephone messages and inquiries within 24 hours of receipt and to written inquiries within one week of receipt