Senior Workers Compensation Claims Adjuster

BUILDERS INSURANCE GROUP INC-posted about 15 hours ago
Full-time • Mid Level
Onsite • Vinings, GA
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The Senior Claims Adjuster determines compensability, sets reserves, and approves payment, in accordance with industry and company Claims’ best practices. The Senior Adjuster analyzes and interprets statues and regulations applicable to case facts in order to render appropriate legal and ethical decisions while managing claims in a prompt and thorough manner from inception through closure.

  • Manage a caseload of limited coverage and medium to severe claims with authorization to resolve cases within a designated monetary threshold. Develop and implement impactful strategies to negotiate and resolve claims within established parameters. Strive to achieve fair and equitable outcomes while steadfastly upholding company and departmental protocols and standards.
  • Deliver quality customer service to all parties involved in the claim process, ensuring prompt and efficient delivery of appropriate benefits. Actively participate in meetings or visits with agents, insurers, and policyholders to cultivate professional relationships and facilitate effective issue resolution.
  • Conduct investigations into losses utilizing various techniques such as interviews, recorded statements, and thorough documentation. Diligently gather and preserve evidence.
  • Identify opportunities for subrogation or instances of potential fraud. Verify, analyze, and apply coverage correctly to each case based on a thorough analysis of facts and pertinent statutory case law. Scrutinize bills, determine necessary actions, and process claims accordingly, prioritizing cost-effective resolutions.
  • Prepare concise and timely reports to facilitate efficient claims processing. Keep agents, insurers, agency operations, and the corporate Claims Department informed of file status and pertinent developments. Ensure accurate and timely filing of all state forms required for claims processing; prepare necessary reports for large loss and reinsurance carriers.
  • Establish reserves and authorize payments in alignment with established procedures.
  • Scrutinize contracts to evaluate risk transfer and assess duty to defend and indemnify additional insured parties.
  • Manage the litigation process in an efficient and effective manner. Determine the necessity for, and provide guidance to defense counsel, independent adjusters, or technical experts, while monitoring and managing their expenses. Attend hearings, pre-trial settlements, conferences and trials.
  • Assess the need for independent medical evaluations, second opinions, nurse or physician reviews, and make referrals. Evaluate the need for external services such as surveillance, field adjusters, or field case managers or coordinating referrals.
  • Maintain detailed documentation of claims activity in claim notes, regularly reviewing and updating diaries and claim notes for all open claims.
  • Meet or exceed expected quality performance guidelines to uphold service standards.
  • Participate in professional development through training programs to stay updated on workers’ compensation laws, rules, and regulations.
  • Identify cases necessitating large loss and/or reinsurance reports, ensuring comprehensive management.
  • Conduct thorough file reviews at various stages of the claims process.
  • Contribute to the training of workers’ compensation claim staff under the guidance of management.
  • Serve as a technical expert and offer support to management.
  • Monitor litigated files to ensure adherence to litigation management protocols.
  • Utilize Insurance Service Office (ISO) decision net and claim search inquiries.
  • Respond to complaint calls and other inquiries, excluding those related to Department of Insurance (DOI) complaints, with professionalism and efficiency.
  • Performs other duties as assigned.
  • Bachelor's degree or equivalent combination of education and/or experience in the insurance field
  • Five or more years of workers’ compensation experience including complex case processing
  • Licensed in multiple jurisdictions with a professional claims designation
  • Knowledge of applicable state laws across territories of operation
  • Knowledge of claims policy, procedures, fiduciary guidelines and best practices
  • Skill in interpersonal interactions, with the ability to collaborate effectively with individuals at all organizational levels and with external stakeholders; skill in customer service, problem-solving time management and conflict resolution
  • Capacity to work autonomously while ensuring transparent communication with internal leadership
  • Skill in planning, time and organizational management; ability to multi-task effectively while paying attention to detail
  • Proficient in both verbal and written communication with the ability and commitment to maintain confidentiality
  • Proficient with Microsoft Office Suite and function specific software applications
  • Competitive Salary
  • Bonus Structure
  • Profit Sharing
  • Medical, Dental, Vision Insurance
  • Employer Paid Short Term Disability
  • Employer Paid Long Term Disability
  • Employer Paid Life Insurance
  • Voluntary Life Insurance
  • 401K with Company Match
  • PTO
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