Claims Adjuster I

New Mexico Mutual Casualty Company • Albuquerque, NM

2d

About The Position

This position is responsible for the adjudication of all assigned claims in accordance with the Act, governing rules and regulations, related case law and company procedures. Case complexity assignment is determined by the experience and qualifications of the adjuster. This position will demand quality claim handling expertise, Service Excellence standards, and timely indemnity, medical and expense benefit management.

Requirements

• Bachelor’s Degree from an accredited college or university.
• A minimum of one year of workers' compensation claims experience is preferred. Additional relevant experience considered in lieu of education.
• Demonstrated proficiency in:
• State required adjuster's license
• Adhere to values and mission by demonstrating Service Excellence, Trust, Ownership, One team and Boldness in thought and action.
• Develops and maintains positive working relationships with team members, customers, co-workers and management by demonstrating effective communication and collaborative skills.

Nice To Haves

• Related professional certifications preferred

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Number of Employees: 101-250 employees