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Trean Corporation · 1 day ago

Claims Adjuster

Boise,ID,US

Full-time

Onsite

Entry Level

2+ years exp

Trean Corporation is seeking a Claims Adjuster to manage workers compensation claims. The role involves ensuring timely adjudication of claims, compliance with regulatory requirements, and effective communication with all parties involved.

ConsultingFinancial ServicesInsurance

Responsibilities

All new lost time claims require an initial contact with the employer, the injured worker and the medical provider. This must be done within 24 hours of receipt of the claim or notification of a claim

Ensure that all claim determinations and payments are completed timely including but not limited to, acceptance/denial letters, wage determination letters including required enclosures and appeal forms. In jurisdictions requiring the letters be provided in Spanish and English the adjuster is responsible to make sure all letters are completed

The initial payment of TTD is to be completed within 14 days from the receipt of an accepted claim. Wage information is to be solicited from the employer and either an average weekly wage or average monthly (jurisdiction dependent) be established

In the event actual payroll documentation cannot be obtained from the employer an “estimated wage” is established and a payment reconciliation is done when the verified wage is secured. Initial compensation benefits should NOT be delayed due to the failure of the employer to provide wage documentation

Timely claims determinations for all services including but not limited to: acceptance, denials, authorizations for treatment, benefit payment start, termination are to be included within the statutory or regulatory time frames of the jurisdiction

Denials requiring certified mailing are to be completed timely with appropriate tracking

Regulatory notices are to be completed timely when required by jurisdictions

Approvals and denials of medical bills should be completed within 24 hours of receipt so bills can be repriced and paid timely

Identify the medical providers and medical treatment plan and ensure timely and appropriate medical care is provided to the injured worker

In cases requiring complex or unusual medical care a nurse case manager is to be assigned to facilitate the timely and appropriate care

All communications with all parties and reference to all determinations and correspondence are to be included in the claim notes

Each office is “paperless” offices, and all documents need to be scanned and added to the claim claims system and a claim note generated

Manage the legal aspects of the claim and appropriately assign and direct designated attorneys

Assign claims for investigations, including surveillance, medical surveys and social media checks when required and seek supervisor support on related questions

Ensure that all bills for various expenses, including legal bills, managed care bills and similar expenses are paid timely or direct claims assistants to pay such when appropriate

Answer phone calls immediately when in the office

Return all calls and voice mail messages within 24 hrs

Respond to all e-mails when required within 24 hrs

Direct claims assistants to facilitate adjuster assignments as required. This includes directing clerical staff in duties such as copying documents, scheduling medical appointments for injured workers and filing of documents

Coordinate assignments with the supervisor of the assistants

Monitor claims for reinsurance/excess insurance reporting and provide initial reports and quarterly updates on all claims meeting reporting requirements

Performs other activities, assignments and duties as assigned