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New Mexico Mutual · 1 day ago

Claims Adjuster I

Albuquerque,NM,US

Full-time

Onsite

Entry Level

1+ years exp

New Mexico Mutual is a company focused on providing quality insurance services. They are seeking a Claims Adjuster I responsible for adjudicating assigned claims in accordance with relevant laws and company procedures, ensuring timely and accurate benefit payments, and maintaining compliance with corporate policies.

Financial ServicesInsuranceService Industry

Responsibilities

Evaluate, analyze and determine compensability, causation, offsets and exposures of basic workers compensation insurance claims in accordance with applicable law, corporate policy, best practice and prescribed authorities

Verify claim information including but not limited to: documentation of the claim history; taking recorded statements from workers and witnesses, identify subrogation opportunities, coordination of medical care

Document all activities in the claim management system

Responsible for outside legal counsel assignments, RTW strategies with policyholders, implement medical case management strategies with nurse case managers and all other expert assignments

Upon determination of compensability: Set and monitor reserves according to company policies and the worker’s injury, issue benefit checks in accordance to statutory requirements, and demonstrate proficiency in the application of state statutes, related case law and to interpret and comply with company claims standards, policies and procedures

Ensure the timely and accurate statutory/benefit payments within the established time frames and guidelines

Prepare and participate in mediation conferences and other authorized legal or regulatory proceedings before the regulatory agencies and courts of law

Maintain a diary on all open claims

Document all relevant information to provide a clear history of events and a proper audit trail

Set review dates based on claim complexity or standard review criteria

Detect and report reasonable suspicions of insurance fraud by claimants, medical or legal providers, policyholders or other individuals related to claims

Maintain claim records in compliance with applicable law, corporate policies and retention schedules