Workers Compensation Adjuster

We are in need for a full-time Senior Claims Examiner to support our Boerne office right outside San Antonio located on Interstate Hwy 10 West. Our offices are open for business Monday-Friday from 7:30 a.m. to 5:30 p.m.   The Senior Claims Examiner will adjust workers’ compensation claims from inception through settlement and closure, ensuring timely processing of claims and payment of benefits, managing and directing medical treatment, setting reserves, and negotiating settlements.

PRINCIPAL DUTIES AND RESPONSIBILITIES

Incumbent must have the skills, ability and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation:

• Establish contact with employer to review issues
• Respond to inquiries from the employer, employee, doctors and attorneys
• Establish and maintain appropriate reserves
• Review legal correspondence and medical reports
• Evaluate and approve medical procedures and treatment
• Administer benefits and ensure appropriateness of all payments
• Investigate coverage, liability and monetary value of claim
• Review medical and legal bills for appropriateness
• Discuss appropriateness of medical treatment with medical case manager
• Determine compensability
• Monitor and assist litigation
• Negotiate settlement of claim, liens, rehabilitation plans, etc
• Prepare and present reports to clients
• Appropriately close claims
• Help resolve client billing and payment inquiries
• Investigate complaints from injured workers
• Document and code the claim files and claims system with all relevant information
• Maintain and update action plans within specified time frames
• Provide direction to Claims Assistants and Claims Technicians and assist with training, coaching, and mentoring as needed for them to support daily claims tasks
• Contact with employers, employees, attorneys, doctors, vendors and other parties
• Provide customer service and support to clients and claimants
• Work collaboratively with attorneys to draft settlements and assist with litigation strategies
• Negotiate settlements
• Authorize and negotiate cost of medical treatment and supplies
• Internal communication with staff
• Prepare professional, well written correspondence and other communications

ESSENTIAL JOB REQUIREMENTS

The requirements listed below are representative of the knowledge, skill, and/or ability required.

• High school diploma required, college degree preferred
• Administrators Certificate from Self-Insurance Plans will be required within one year of employment if not already obtained.
• A Texas 03 Workers’ Compensation license is required
• An 08 All Lines License is preferred
• 3+ years recent workers compensation claims handling experience
• Solid knowledge of workers compensation laws, policies and procedures
• Well-developed verbal and written communication skills
• Strong attention to detail and the ability to research and resolve problems
• Excellent organizational skills
• Ability to manage multiple tasks simultaneously
• Ability to work independently and in a group setting
• Ability to operate standard office equipment (fax, phone, printer, scanner, etc.)
• Ability to work in a paperless environment
• Ability to type quickly, accurately and for prolonged periods
• Must demonstrate accuracy and thoroughness in work product
• Ability to sit for prolonged periods of time
• Infrequent lifting of up to 20lbs may be required
• Computer literate and experience navigating various computer systems, including MS Word, Excel and Outlook and database management.
• SIMS program experience preferred but not required
• Ability to learn additional computer programs
• Completion of IEA or equivalent courses
• Reasoning ability, including problem solving and analytical skills, i.e., proven ability to analyze facts, identify issues and make appropriate recommendations and solutions for resolution
• Proficiency in determining case value and negotiating settlements
• Understanding of medical and legal terminology
• Mathematical calculating skills
• Proven ability to analyze facts, identify issues and make appropriate recommendations and solutions for resolution
• Ability to carefully review records prior to sending to correct parties