Medical Only Adjuster - TPA

Relation Insurance Services•Stuart, FL

14d

About The Position

The Medical Only Adjuster is responsible for confirming the compensability of workers’ compensation medical-only claims and closely monitoring assigned files for potential lost time exposure. The individual in this role maintains regular communication with insureds, claimants, employers, and medical providers and provides operational support to the broader claims team to ensure timely, accurate, and compliant claim handling.

Requirements

High school diploma or equivalent.
1 year of experience in claims processing.
Strong verbal and written communication skills with the ability to interact professionally with internal and external stakeholders.
Ability to follow written and verbal instructions and adhere to established policies and procedures.
Proficiency in Microsoft Office, including Word and Excel; ability to learn new systems and software applications.
Demonstrated ability to manage multiple tasks, prioritize deadlines, and work effectively in a fast-paced environment.
Strong attention to detail and organizational skills.
Ability to communicate effectively and build professional working relationships at all levels of the organization.
Commitment to maintaining confidentiality and handling sensitive information appropriately.
Consistently represents the company with professionalism, tact, and discretion.

Responsibilities

Confirms compensability of medical-only workers’ compensation claims in accordance with jurisdictional requirements and company guidelines.
Maintains regular contact with clients, claimants, employers, and medical providers to obtain work status and monitor claim progression.
Monitors medical-only claims for indicators of potential lost time and escalates files to a Claims Adjuster as appropriate.
Assesses claims for potential subrogation opportunities and places appropriate parties on notice when identified.
Authorizes medical treatment and confirms medical necessity and major contributing cause as warranted.
Reviews, approves, and processes medical bills in a timely and accurate manner.
Ensures all medical and hospital bills contain required information and documentation.
Returns incomplete or incorrect bills to providers promptly for correction.
Enters bills for payment and ensures timely processing in accordance with service standards.
Maintains appropriate reserves on medical-only claims and updates reserves as needed.
Schedules and coordinates medical appointments and diagnostic testing for injured employees.
Follows up with medical providers regarding treatment status and maximum medical improvement (MMI).
Maintains open and closed claim files and reviews files monthly to ensure timely progression and closure.
Utilizes claim diaries to ensure timely completion of routine claim activities and appropriate file documentation.
Assists Claims Adjusters with indemnity-related tasks as needed.
Maintains accurate, organized, and up-to-date claim documentation.
Effectively utilizes available technology and tools, including emerging and AI‑enabled solutions, to support efficient workflows, accuracy, and a positive client service experience.
Special projects and other duties as assigned.