Job Description

Workers' Compensation Claims Adjuster

Job Summary

Seeking a seasoned Workers' Compensation Claims Adjuster to join a Third-Party Administration team. The role involves managing all aspects of workers' compensation claims, including determining compensability, verifying coverage, administering benefits, negotiating claim resolutions, and providing support to injured employees, employers, and medical/legal professionals throughout the claim lifecycle.

Compensation Package

• Medical, dental, and vision insurance
• Life insurance
• 401(k) plan with company match

Responsibilities

• Receive and manage newly reported claims.
• Maintain and update claim notes throughout the claim lifecycle.
• Record claim information in the electronic database.
• Conduct interviews with claimants, insureds, medical professionals, and witnesses to determine claim validity.
• Communicate claim compensability decisions to claimants, employers, and medical providers.
• Set appropriate reserves based on the nature and extent of injuries.
• Calculate lost time wages, administer disability payments, and manage payment schedules.
• Coordinate independent medical examinations and prepare relevant documentation for review.
• Maintain regular correspondence with claimants, insureds, and nurse case managers.
• Review and process medical bills through third-party vendors for additional discount opportunities.
• Collaborate with claimants and insureds to facilitate early return-to-work initiatives.
• Partner with legal counsel to protect insureds' interests on litigated claims, including providing necessary documentation and evaluating claim exposure.
• Attend settlement conferences, mediations, and hearings on behalf of the insurance company/insured.
• Review and approve defense attorney bills within authority limits.
• Work with underwriting and risk management teams to provide relevant loss information and identify trends.
• Respond to state requests for health cost disputes, applications for hearings, and penalty assessment letters.
• Identify subrogation opportunities and pursue recovery.
• Lead claim reviews with clients as requested.
• Perform other duties as assigned.

Qualifications/Requirements

• Minimum of 10 years of experience adjusting Workers' Compensation Claims in California.
• SIP Certification is required.
• Bilingual proficiency in Spanish and English is required.
• Current with Continuing Education Units (CEUs).
• Proficiency in the Microsoft Office suite.
• Strong knowledge of relevant workers' compensation laws.
• Solid understanding of medical terminology and familiarity with medical case progression.
• Excellent oral and written communication skills.
• Exceptional attention to detail and organizational abilities.
• Strong negotiation skills for resolving issues and settlements.
• Commitment to providing outstanding customer service, including timely responses to inquiries.
• Adaptability to changing technologies and the ability to learn new systems.
• Proven ability to establish and maintain effective working relationships with others.

#LI-BR1