Claims Adjuster-Workers' Compensation Jobs

SUMMARY

The Claims Adjuster is primarily responsible for analyzing workers' compensation claims to determine the benefits due. This role is also responsible for ensuring the ongoing adjudication of claims within service expectations and company best practices pursuant to all state, legal, statutory, and regulatory bodies.

DUTIES & RESPONSIBILITIES

• Manage the medical treatment and return to work process throughout the life of the claim.
• Adhere to Method Best Practices, Method Claims Protocol, and Claims Handling Guidelines.
• Exercise accurate discernment and decision-making to analyze claims exposure and to plan and document the proper course of action to move the claim to resolution.
• Calculate the average weekly wage and indemnity benefits owed.
• Maintain appropriate claim file documentation and accurate claim coding.
• Coordinate vendor utilization while considering claim cost containment techniques and outcomes, including but not limited to nurse case management, surveillance, etc.
• Communicate claim activity regularly to any relevant internal and external stakeholders, including injured workers, policyholders, medical providers, and carriers, when appropriate.
• Ensure compliance of claims handling requirements pursuant to all state, legal, statutory and regulatory bodies.
• Manage claim recoveries, including but not limited to Second Injury Fund, subrogation, and Medicare offsets.
• Understands, analyzes, and applies policy components to evaluate coverage.
• With minimal supervision, investigate claims, including but not limited to reviewing the first report of injuries, medical records; contracts; contacting insureds, injured workers, medical providers, and other parties to determine compensability in a timely manner.
• Perform other duties as requested and assigned.
• Ensure all benefits are paid timely and in accordance with jurisdictional requirements.
• Timely prepare state filings within the state statutory regulations.
• Notify management of large loss exposure, denial, coverage disputes, subrogation potential, or other matters requiring escalation or collaboration.
• Evaluate exposure of claims by reviewing medical records and claim facts to determine causal relatedness of medical conditions.
• Exercise discretion and independent judgment with respect to evaluating and managing claims, including determining reserve amounts and document rationale.
• Maintain knowledge of jurisdictional requirements and applicable case law for each State, including appropriate licensure and continuing education requirements.

COMPETENCIES

• Excellent customer service, written and verbal communication skills
• Detail-oriented with the ability to work in a team environment
• Ability to exercise discretion and independent judgment
• Ability to prioritize and balance multiple projects simultaneously
• In-depth knowledge of workers' compensation insurance principles and laws, as well as cost containment principles
• Results-driven, proactive, and able to work autonomously
• Strong analytical, critical thinking, and problem-solving skills

SUPERVISORY RESPONSIBILITY

This position will not have supervisory responsibilities.

TECHNICAL SKILLS REQUIRED

Proficient in Microsoft Office Suite, PDF Professional, G Suite, or similar software.

WORK ENVIRONMENT & PHYSICAL DEMANDS

Unless fully remote, this position operates in a professional office setting and routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. This is largely a sedentary role with prolonged periods of sitting at a desk and working on a computer. However, some filing is necessary and may require the ability to lift files, open filing cabinets and bend or stand on a stool as necessary.

POSITION & EXPECTED HOURS

This is a full-time, salaried exempt position. Typical work hours and days are Monday through Friday, from 8:00 am to 5:00 pm. Some flexibility in hours is allowed, however, the employee must be available during the "core" work hours of 9:30 am to 3:30 pm and must work 37.5 hours each week.

TRAVEL

Minimal to no travel required.

EDUCATION & EXPERIENCE

• A combination of education and experience in a TPA or brokerage environment will be considered
• At least 3-5 years of experience in workers’ compensation claims experience is preferred.
• Bachelor’s degree from an accredited college or university preferred
• State adjuster’s licenses as required
• California Designation required

BENEFITS

• Hybrid/Remote/On-site Work
• 4 Weeks' Paid Parental Leave
• 37.5 Hour Work Week
• Medical, Dental, and Vision
• 401k Matching
• HSA Contribution

About Method

Method Workers’ Compensation is a portfolio of workers’ comp companies with the same mission: minimizing the human and financial cost of workplace injuries. We mitigate workplace injuries and deliver exceptional healthcare outcomes for injured workers, expediting a return to work, preserving families’ livelihoods, and enhancing employers’ productivity. We maintain in-house expertise in claims management, medical bill review, underwriting, and loss prevention for high-hazard, high-mod, and mid-market risks. From submission to claim, we’re there every step of the way, improving outcomes for everyone involved.

Method currently operates in all states.