Workers' Compensation Claims Adjuster I

At EMC, you'll put your skills to good use as an important member of our team. You can count on gaining valuable experience while contributing to the company's success. EMC strives to hire and retain the best people by engaging, developing and rewarding employees.

This position is eligible to work from home anywhere in the United States

Summary:

Exercises independent judgment in the investigation, evaluation, negotiation, and disposition of workers' compensation claims, within limitations of authority outlined in the Claims Guide. Communicates with insureds, agents, and experts regarding coverage and claim status or questions.

Essential Functions:

• Reviews the claim notice, contracts, state statutes, and policies to verify the appropriate coverage, deductibles, jurisdiction and compensability.

• Initiates timely contact with insureds and claimants to explain the claims process

• Obtains statements from insureds, injured workers, witnesses, and any other pertinent parties as appropriate

• Documents claim activities, reserve analysis, summaries of reports in the claim system

• Sets timely, adequate reserves in compliance with the company reserving philosophy and methodology

• Identifies, investigates, and proactively pursues opportunities for recovery and subrogation

• Researches medical treatment and diagnosis to gain understanding of claimant's injury and medical history

• Notifies all parties involved that legally require notice per jurisdictional requirements

• Secures and reviews all necessary official reports, claim forms, video and documents

• Reviews medical bills, invoices, and receipts for appropriateness and accuracy

• Notifies the Claims Supervisor of claims requiring reassignment to a more appropriate level of claim handler

• Gathers payment data to calculate wage benefits due and pays accordingly through proper payment channels

• Continues to monitor wage loss data for changes such as overtime, light duty, child-support liens, seasonal and contractual employment, raises, and annual state legislative reviews that impact wage reimbursement and adjustments

• Coordinates return to work with medical providers, insured and claimants

• Coordinates appropriate medical care, including use of appropriate cost containment techniques and resources

• Maintains accurate and timely diaries on all files to bring claims to resolution

• Assists with marketing and agency duties as needed

• Drafts independent medical exam (IME) and denial letters with supervisor oversight when appropriate

• Prepares settlement evaluations, negotiation ranges and target settlement numbers prior to negotiation

• Investigates and resolves questions of compensability and communicates with all relevant parties to resolve coverage issues in a timely manner

• Works with attorneys, attending mediations, settlement conferences etc. to resolve claims

• Assists claims team members as needed in handling of claims

• Submits referrals to the Special Investigation, Subrogation, external Medical Management, and internal Medical Review Units as Appropriate

• Markets On Call Nurse (OCN), Return to Work (RTW), and Select Preferred Provider (SPP) programs to insured's and identifies non-use for corrective measures

• Prepares risk alerts for Underwriting and Risk Improvement

Education & Experience:

• Bachelor's degree or equivalent relevant experience

• One year of workers' compensation claims adjusting experience or related experience

• Attainment of all applicable state licenses within one year of hire

• Relevant insurance designations preferred

Knowledge, Skills & Abilities:

• Working knowledge of the theory and practice of the claim function

• Good knowledge of insurance contracts, medical terminology and substantive and procedural laws

• Ability to adhere to high standards of professional conduct and code of ethics

• Strong knowledge of computers and claims systems

• Strong organizational and written and verbal communication skills

• Good investigative and problem-solving abilities

• Occasional travel required; a valid driver's license with an acceptable motor vehicle report per company standards required if driving

Per the Colorado Equal Pay for Equal Work Act, the hiring range for this position for Colorado-based team members is $58,618.44 - $75,262.27. The hiring range for other locations may vary.

Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.

All of our locations are tobacco free including in company vehicles.