Workers Compensation Lead Adjuster
Location: Nebraska
Description: Affinity Executive Search is at the momment seeking for Workers Compensation Lead Adjuster right now, this career will be placed in Nebraska. For detail informations about this career opportunity please read the description below. JOB SUMMARY: Investigates, coordinates and processes the most complex medical and indemnity workers compensation claims involving multiple states to determi! ne compensability, entitled benefits, average weekly wage and benefit rate, in accordance with applicable State Workers Compensation Statute. Promotes and provides outstanding customer service. Establish timely and appropriate case reserves in accordance with Best Practices and manages claims to appropriate resolution. Provides timely and accurate claims administration according to contract and/or client service plan and within applicable state laws.
JOB RESPONSIBILITIES:
1. Completes state and other regulatory reports/forms to include EDI forms as required by each State Workers Compensation Statute or State Regulatory Rules.
2. Assist with assignment of new claims.
3. Employs appropriate claims management techniques and direct intervention (I.e., independent medical examinations, referral for rehabilitation, utilization review, etc.) to manage each claim. Maintains contact with policyholders and injured worker and pursues return to work initiati! ves. Utilizes effective TNCM or Field Nurse Case Management se! rvices to assist with managing medical care and return to work activities. Consults with internal CMS for future care needs and issues of LE. Evaluates exposures, manages ongoing case reserves in accordance with Best Practices and negotiates settlements as appropriate. Documents significant activity and decision in each claim via on-line claim system.
4. Manages litigated claim issues in accordance with Best Claims Practices. Obtains appropriate litigation budgets and develops appropriate POA in partnership with counsel, and manages litigation expenses of Trial Division or approved outside counsel.
5. Evaluates all pertinent information and works in conjunction with claimant/client to pursue most appropriate claims resolution.
6. Fully investigates and pursues third party recoveries and any applicable deductibles. May utilize the services of recovery unit, and/or partner with designated outside counsel/trial division, or by giving notice of lien to plaintiff cou! nsel handling third party litigation. Claim Zone Field assist referrals and/or outside consulting expert may be utilized to gather, obtain and secure critical information.
7. Opens, closes and adjusts reserves in accordance with company practices designed to ensure reserve adequacy. Recommends Special Reserves where necessary.
8. Maintains current knowledge of: court decisions which may impact the claims function; current principles and practices in the claims function; material damage techniques and repair technology innovations; and policy changes and modifications. May be required to maintain knowledge of other functions within assigned discipline. This may require attendance at various seminars or training sessions.
9. Serves as a mentor to less experienced claims associates and assists with training/presentations as assigned by claims management.
10. Assists with the training and development of other claims associates.
11. Serves as referral ! point for claims issues from team, other claims units, customers and le! gal. May serve as venue specific or topic specific expert to unit and serve as a ready resource to Claims Specialists for guidance.
12. Reviews files for Medicare reporting obligations and submits appropriate Medicare query,ORM and TPOC reports.
13. Provides appropriate notices to policyholders and injured employee on complex claims in accordance with applicable state Workers Compensation statute, and obtains appropriate forms and documentation to verify employee/employer relationship and average weekly wage. Completes and files appropriate FROI and SROI's as required by individual State Workers Compensation Statute and EDI reporting regulations.
14. Assists with or is assigned special projects for completion under direction of Claims Manager. Will serve as designated project representative for new system enhancements/implementations/pilot projects.
15. Will handle claims involving MSA's at time of settlement and which may be funded by a Structured Settlemen! t.
16. Consults claims staff and defense counsel for discovery processes, suit file/trial strategy as related to case-specific issues.
17. Consults claims staff and defense counsel for discovery processes, suit file/trial strategy as related to case-specific issues.
18. Delivers a positive customer service experience to all internal, external, current and prospective customers.
19. May periodically conduct customer/account visits to review reserves and discuss status of significant claims. May also present educational workshops to client personnel.
20. May serve as unit leader when Manager is out of office.
21. Will serve as a role model and mentor to less experienced Associates.
22. Other duties as assigned.
JOB REQUIREMENTS:
Education: Undergraduate degree or equivalent experience preferred. Advanced degrees in law or related discipline desirable.
Licenses/Designations: Successful completion of required cla! ims certification schools/courses. Professional development such as IIA! or CPCU preferred. State licensing where required.
Experience: Five years work experience in workers compensation claims. Successful completion of formal claims training program per business unit standards.
- .
If you were eligible to this career, please email us your resume, with salary requirements and a resume to Affinity Executive Search.
If you interested on this career just click on the Apply button, you will be redirected to the official website
This career starts available on: Sun, 05 May 2013 14:38:34 GMT