[Hiring] Senior Workers Compensation Claims Adjuster @INSURICA INC

Role Description

The Worker’s Compensation Claims Adjuster will manage a caseload of approximately 150 open claims, exercising good judgment while resolving claims according to our established procedures and best claims practices, in accordance with statutory, regulatory, and ethics requirements.

• Receive and review initial workers’ compensation claims, verifying the accuracy and completeness of claim forms and supporting documentation.
• Conduct thorough investigations to determine validity and extent of injury; interview the injured employee, employer(s), and any witnesses, as well as review medical reports and accident reports to determine causality and compensability.
• Effectively communicate with the injured worker, employer(s), medical professionals, and legal representatives, as needed, providing ongoing updates and information to all parties involved in the claim process.
• Make appropriate determinations on the approval or denial of claims, based on investigation findings and applicable laws; calculate correct benefit amounts, including medical expenses, wage replacement, and any other necessary compensation.
• Manage and monitor open claims to ensure timely and appropriate processing; coordinate return-to-work programs and rehabilitation services.
• Effectively maintain detailed and accurate records for each claim; prepare and submit required documentation and reports to regulatory bodies.
• Timely initiation, maintenance, and termination of temporary, impairment, and supplemental income benefits.
• Identify and pursue subrogation when there is 3rd party negligence, and negotiate a fair settlement for all parties involved.
• Address and resolve any disputes or issues that arise during the claim process.
• Serve as a subject matter expert and mentor to Workers’ Compensation Claims Adjuster staff members, providing guidance and direction, as needed, for difficult or unusual claims or client situations.
• Review all activities relating to the public, customers, and companies to avoid issues involving potential errors and omissions and ensure compliance with workers’ compensation laws and regulations.
• Participate in seminars and other training to maintain required licenses and for knowledge and skill development.

Qualifications

• 5 – 7 years of previous workers’ compensation claims handling experience preferred.
• Possession of a current Texas Workers’ Compensation Adjuster License or an All-Lines Adjuster License is required.
• Spanish language skills (speak and understand) preferred, but not required.

Requirements

• Strong judgment and decision-making skills, with the ability to effectively analyze claims exposure to determine the proper course of action.
• Extensive knowledge of Workers’ Compensation law, industry standards, and medical and legal terminology.
• Strong working knowledge of the Texas Workers’ Compensation Act, including specific rules and case law.
• Strong working knowledge of various medical services normally provided to injured workers.
• Knowledge of EDI (Reporting requirements for the State of Texas).
• Excellent organizational skills, demonstrating attention to detail, accuracy, and ability to meet deadlines.
• Ability to work within a fast-paced, changing priority environment.
• Self-motivated, with the initiative to prioritize and be self-directed.
• Regular and punctual attendance is required.
• Ability to communicate effectively, both verbally and in writing.
• Excellent interpersonal skills, with the ability to interact effectively with both colleagues and managers, across all levels.
• Ability to promote and maintain a team environment, willing to find accommodating solutions for our customers, companies, and the Agency.
• Ability to successfully adhere to company policies and procedures, as well as maintain strict confidentiality.

Work Conditions

• Ability to perform approximately 90% sedentary work, exerting up to 10 pounds of force occasionally, and negligible force frequently.
• Ability to lift up to 20 pounds, occasionally.
• Requires operation of a computer workstation, including keyboard and video display.
• All requirements may be modified to reasonably accommodate physical or mental impairment.