WC Complex Med Only Adjuster -Charlotte, NC (Hybrid)

Selective Insurance Company of America•Charlotte, NC

9h•Hybrid

About The Position

Selective Insurance is looking for a WC Complex Med Only Adjuster for our Charlotte office. This is a hybrid role with 2 days in office and 3 days remote. Experience handling claims in IA, IL, IN, KS, MI, MO, WI preferred. Responsibility includes effective and timely communication with employer, employee, and medical provider. Investigate medical only claims to determine coverage, compensability, and subrogation potential based on jurisdictional guidelines. Manage claims in multiple jurisdictions. Continuous review and analysis of these claims to ensure that the reserves are appropriate. Manage administration of benefits and claim resolution. Obtain relevant information necessary for a thorough investigation. Freeze facts of claims and make timely decisions. Provide compelling customer service. All job duties and responsibilities must be carried out in compliance with applicable legal and regulatory requirements.

Requirements

Knowledge of workers compensation statutes, coverage, and case law.
Excellent written and verbal communication skills.
Working knowledge of medical treatment and terms as related to medical only workers compensation claims.
Critical thinking skills to assess compensability of WC claim as it relates to the facts and law.

Nice To Haves

College degree preferred.
1-3 years claims experience preferred.
Experience handling claims in IA, IL, IN, KS, MI, MO, WI preferred.

Responsibilities

Receives assigned complex medical only claims for investigation through telephone or written communication with insureds, claimants, and providers to determine coverage, compensability, subrogation potential, and appropriate course of action.
Handles mostly non-indemnity claims (no lost time within waiting period), medical causality, denied claims (not compensable and not covered), and medical claim petitions. On occasion will manage claims with minimal permancy benefits (indemnity). Establishes initial and subsequent reserves on complex medical only claims with a general exposure of less than $30,000.
Processes claims which include the following activities: Making contacts, setting reserves, evaluating claims for exposure, establishing timely reserve adjustments during the life of the file, making timely payments, and resolution.
Documents claim files and maintain control of work through documentation or diary system.
Manages medical only claims with some complexity that may require a nurse consult, diagnostics, and minor medical procedures. Understand medical terminology and injury mechanism. Ability to recognize comorbidities that may complicate injury and recovery.
File state forms timely in accordance with statutory guidelines.
Ensures compliance with company, state, and federal regulations. Makes certain data is accurate and updated timely for electronic data interchange with state and Medicare.
Handle disputed facts, benefits, compensability, coverage, medical causality, and relatedness.
Receives assigned claims from the medical only unit , notice of loss coordinator, or lost time adjusters.