Senior WC Claim Adjuster

Key Responsibilities

• Evaluate claim detail including Florida Statute and case law to determine compensability and total value of the claim; set and adjust reserve accordingly
• Initiate investigation and assign defense counsel when appropriate
• Initiate accurate indemnity payments in a timely manner and maintain diary for ongoing payments
• Timely proper completion of State filings
• Handle EDI filings and rejections in conjunction with EDI adjuster
• Monitor medical treatment in conjunction with assigned Nurse Case Manager
• Review document and approve medical bills for payment within three days of receipt
• Authorize appropriate medical services as outlined per Florida Statute 440.13
• Determine whether vocational rehabilitation services are needed for an employee to return to work
• Coordinate light duty availability and reasonable accommodations with medical providers and employers
• Maintain adequate reserves for life of claim utilizing reserve worksheets ODG Guidelines Workers Computation software and Davies Claims North America reserving philosophy
• Attend client meetings as necessary and maintain regular telephone contact to ensure client satisfaction
• Maintain diary and workflow requirements
• Maintain working knowledge of FL Workers Compensation Statutes and Rules and their application
• Direct defense counsel in handling of litigation claims with defense input make timely decisions regarding litigated issues
• Protect Medicares interest in conjunction with MMSEA Section 111 Reporting requirements
• Review claims for possible red flags
• Demonstrate capability of identifying and pursuing subrogation contribution indemnification or other opportunities to compel responsible third parties to bear their share of the settlement burden
• Request reimbursement at least quarterly and follow up for timely receipt from excess carrier(s)
• Adhere to client profile instructions
• Report any overall account or client concerns to the supervisor or upper management
• Report any E&O concerns to the QA Manager and Executive Vice President
• Maintain 97% claim closure ratio

Skills knowledge & expertise

• College degree
• Multiple years experience handling several types of claims
• Presumption claims handling experience
• Experience with depositions mediations and litigation
• Experience with IDatix Reference Books-Periodicals Workers Computation ISO ShoreTel
• 3-5 years of Lost Time/Legal claims handling experience; preferred 5 years
• Possess FL-All Lines Adjuster or Workers Compensation License and maintain CEU credits for license
• Previous experience with settling claims
• Experience with Microsoft Office Suite
• Proactive independent and takes initiative with consistent follow through
• Superb communication skills verbal and written conducted in a timely manner
• Superior time management skills with capability of working with and meeting deadlines
• Exceptional capability to multi-task and prioritize with excellent organization and documentation skills in a fast-paced dynamic work environment
• Excellent team player with interpersonal skills
• High level attention to detail and problem-solving skills
• Capable of working collaboratively and independently with minimal supervision
• Exhibit discretion with sensitive and confidential information
• Display a comfort level working with key people at all levels within an organization

Equal Employment Opportunity & Legal Notices

• Medical dental and vision plans to support your health and that of your family
• A 401(k) plan with employer matching
• Timeoff policies including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for nonexempt employees
• Paid holidays
• Life insurance and shortterm and longterm disability coverage