Independently resolves complex Workers Compensation claims by investigating, negotiating, and settling claims; conducting phone and on-site interviews of various Workers Compensation claims within established guidelines.

Essential Functions and Responsibilities

(Other duties may be assigned)

• Conducts phone and field investigations by interviewing claimants, insureds, and witnesses; securing statements; photographing and/or videotaping accident sites; documenting the claims file with the results.
• Mentors and trains department staff as assigned by leading department roundtable discussions, assisting new hire training and presenting information on emerging trends, cost containment programs and claims handling best practices in workers compensation.
• Supports after-hours claims emergencies by being on call 24 hours per day, seven days per week.
• Acts as main contact for large/dedicated insureds by scheduling meetings to review claims, discussing opportunities for better claim resolution, and providing information regarding new cost containment programs.
• Determines the insurance carriers liability through application of technical expertise by reviewing the facts of the claims, setting claim reserves, calculating and paying the appropriate benefits.
• Determines the desirability of obtaining records review and independent medical examinations (IME) by reviewing the facts of the claim and posing questions to independent medical personnel and taking the appropriate action with the results.
• Promotes early return to work by communicating and coordinating between involved parties.
• Resolves disputed claims independently or with attorney assistance by analyzing state statutes, evaluating evidence and developing a claim resolution strategy.
• Pursues subrogation recoveries from potentially responsible third parties independently by reviewing the facts and determining liability.
• Communicates decisions on claims by responding to communications from: managers, claimants, claimants counsel, insureds, agents, health care providers, state administrators and others.
• Determines the need for medical and vocational management independently by reviewing the severity of the claim, assigning vendors and directing their activities.
• Keeps current with claims through follow-up discussions with injured workers and insureds; makes recommendations to manager regarding reserve changes and future handling of files based on claim facts.
• Ensures accurate file documentation by complying with company procedures and state requirements.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required:

• Bachelors degree in business or related field and 5+ years of workers compensation adjusting experience.

OR

7+ years of workers compensation adjusting experience involving the exercise of discretionary decision-making and increasing levels of claim severity as determined by Society Insurance.

• Valid drivers license and a satisfactory driving record as determined by Society Insurance.

Preferred:

• Bachelors degree with 5+ years of workers compensation claims handling experience.
• Proficient investigative skills, demonstrated through experience.
• Continued education in related field and/or experience with medical terminology and workers compensation laws and procedures.
• Completed the AIC designation or equivalent coursework.
• Experience handling insurance policies and coverage, claim payment procedures, insurance regulations, and understanding of medical and legal terminology.
• Communicates clearly and concisely in verbal and written communications.
• Demonstrated knowledge of general office equipment (computer, telephone, calculator, fax machine, headsets and copy machines).