[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.

Job Functions

• 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.

Additional Responsibilities

This job description is intended to describe the level of work required of the person performing the position. Essential functions are outlined; however, other duties may be assigned, as needs arise, or as required to support the essential functions. Specific performance objectives may be developed each year to measure the performance of the tasks and functions listed in this job description.

Remote work opportunities vary by location, department, and business need and are subject to change, as needed. Each manager will provide details on any telecommuting opportunities, as well as scheduling, within their department.

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 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.