Workers Compensation Claims Adjuster II

Intercare Holdings Insurance Services•Orange, CA

68d

About The Position

Summary: Reports directly to the unit Claims Supervisor. In accordance with applicable statutes and in keeping with company rules, regulations, and established performance objectives, is responsible for effectively managing to conclusion an assigned inventory of claim files. Essential Duties and Responsibilities: Perform a three-point contact on all new losses within 24 hours of receipt of the claim to include the claimant, employer, and treating physician to document relevant facts surrounding the incident itself as well as disability and treatment status. Thoroughly and accurately gather evidence regarding ongoing case facts and relevant information necessary for establishing compensability, the need for disability payments, the use of vendors, medical and expense payments, and the reason the claim is still open. Assure that all assigned indemnity claims have an up to date plan of action outlining activities and actions anticipated for ultimately resolving the claim. Form a partnership with the medical case manager to maximize early return to work potential thereby reducing the need for extended disability payments, vocational rehabilitation, and other protracted claims costs. Initiate the referral to the SIU of cases with suspected fraud. Aggressively pursue subrogation from culpable third parties, contributions on multiple defendant cases, and apportionment when there is pre-existing disability. Assure that the claim file is handled totally in accordance with applicable statutes as well as in-force service contracts and company guidelines. Review and approve all vocational rehabilitation plans. Establish, monitor, and adjust monetary case reserves when warranted and in strict accordance with assigned authority levels. Review all medical bills for appropriateness prior to referral to InterMed for payment and posting to the claim file. Exhibit and maintain a courteous and helpful attitude and project a professional image on behalf of the company. Respond to telephone messages and inquiries within 24 hours of receipt and to written inquiries within one week of receipt. Requires a working knowledge of the Labor Code of the State of California as it pertains to workers compensation claims and the legal requirements for handling them. Litigation Management - Direct, manage, and control the litigation process. Handles other duties and tasks as deemed appropriate by the Supervisor or Manager.

Requirements

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Uses reason even when dealing with emotional topics.
Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Responds to requests for service and assistance; Meets commitments.
Interpersonal - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
Team Work - Supports everyone's efforts to succeed.
Bachelor’s degree (B. A.) or equivalent from four-year college or; or 3-5years related experience& training, 5 years without a SIP certificate, or equivalent combination of education and experience.

Responsibilities

Perform a three-point contact on all new losses within 24 hours of receipt of the claim to include the claimant, employer, and treating physician to document relevant facts surrounding the incident itself as well as disability and treatment status.
Thoroughly and accurately gather evidence regarding ongoing case facts and relevant information necessary for establishing compensability, the need for disability payments, the use of vendors, medical and expense payments, and the reason the claim is still open.
Assure that all assigned indemnity claims have an up to date plan of action outlining activities and actions anticipated for ultimately resolving the claim.
Form a partnership with the medical case manager to maximize early return to work potential thereby reducing the need for extended disability payments, vocational rehabilitation, and other protracted claims costs.
Initiate the referral to the SIU of cases with suspected fraud.
Aggressively pursue subrogation from culpable third parties, contributions on multiple defendant cases, and apportionment when there is pre-existing disability.
Assure that the claim file is handled totally in accordance with applicable statutes as well as in-force service contracts and company guidelines.
Review and approve all vocational rehabilitation plans.
Establish, monitor, and adjust monetary case reserves when warranted and in strict accordance with assigned authority levels.
Review all medical bills for appropriateness prior to referral to InterMed for payment and posting to the claim file.
Exhibit and maintain a courteous and helpful attitude and project a professional image on behalf of the company.
Respond to telephone messages and inquiries within 24 hours of receipt and to written inquiries within one week of receipt.
Requires a working knowledge of the Labor Code of the State of California as it pertains to workers compensation claims and the legal requirements for handling them.
Litigation Management - Direct, manage, and control the litigation process.
Handles other duties and tasks as deemed appropriate by the Supervisor or Manager.