115 applicants

Company

EMC Insurance Companies · 1 day ago

Workers' Compensation Claims Adjuster I

Iowa, United States

Full-time

Remote

Entry Level

$59K/yr - $75K/yr

1+ years exp

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Responsibilities

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.

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

Qualification

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Workers' compensation claims adjustingInsurance contracts knowledgeMedical terminologyClaims systemsProblem-solving abilitiesState licensesProfessional conduct

Required

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

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

Preferred

Relevant insurance designations preferred

Company

EMC Insurance Companies

Glassdoor

3.5

EMC Insurance Companies is among the top 60 insurance organizations in the country based on net written premium, and we have more than 2,500 employees.

Founded in 1911

Des Moines, Iowa, USA

1,001-5,000 employees