Claims Adjuster - Texas Non-Subscription

Baylor Scott & White Health•Dallas, TX

40d•Hybrid

About The Position

Under the direct supervision of the Safe Choice Claims Manager the Claims Adjuster is responsible for the review, analysis and processing of assigned claims within their authority limits and consistent with policy and legal requirements. The goal of the position is to provide prompt, efficient delivery of quality service while protecting the assets of the organization. The Claims Adjuster's primary duty includes the exercise of discretion and independent judgment with respect to matters of significant financial impact and confidentiality. HYBRID position - 2 days onsite each week - Dallas, TX

Requirements

EDUCATION - H.S. Diploma/GED Equivalent
EXPERIENCE - 5 Years of Experience

Nice To Haves

Can substitute Bachelors degree for years of experience
Texas All Lines Adjuster License, Non-subscription Experience Preferred

Responsibilities

Promptly investigate assigned non-subscription claims to assess liability and entitlement to benefits.
Confirm applicable coverage; maintain compliance w/ERISA plan document, insurance policies and procedure manuals. Take recorded statements, establish reserve requirements, identify subrogation potential, maintain diary
Review and evaluate medical and loss wages, conduct thorough investigation of the claim through contact with witnesses. Provide status reports to management as needed.
Resolve complex, severe exposure claims, using high service oriented file handling
Responsibility for the preparation of summaries and files for denials, appeals, medical opinions, subrogation and litigation.
Collection of documents and summarizing information.
Providing presentations for committee meetings and any required correspondence.
Applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio
Assign surveillance on appropriate claims
Identifying claims with possible recovery from third parties
Maintains communication with doctors, attorneys, safety specialist, and nurse specialist and outside vendors to provide prompt, economical and professional handling of all claims.
Talking to others to convey information effectively
Communicating effectively in writing as appropriate
Provide and Coordinate training with HR team
Work with Claims Manager for improvements in processes to increase proficiency and supervise effective resolution of all claim inquiries.
Responsible for the approval of lost wages for payroll and for all approvals of medical bills per claim file.
Pay and process claims within designated authority level
Performs other position appropriate duties as required in a competent, professional and courteous manner.