Description:SUMMARYThe Claims Adjuster is primarily responsible for analyzing workers’ compensation claims to determine benefits due.
This role is also responsible for ensuring the ongoing adjudication of claims within service expectations, and company best practices pursuant to all state, legal, statutory, and regulatory bodies in the state of California.
DUTIES & RESPONSIBILITIESWith minimal supervision investigate claims including but not limited to, reviewing the first report of injuries, medical records; contracts; contacting insureds, injured workers, medical providers, and other parties to determine compensability in a timely manner.Understands, analyzes and applies policy components to evaluate coverage.Ensure compliance of claims handling requirements pursuant to all state, legal, statutory and regulatory bodies.
Exercise discretion and independent judgment with respect to evaluating and managing claims including determining reserve amounts and document rationale.
Evaluate exposure of claims by reviewing medical records and claim facts to determine causal relatedness of medical conditions.
Manage the medical treatment and return to work process throughout the life of the claim.Adhere to Method Best Practices, Salus Claims Protocol, and Claims Handling Guidelines.Maintain appropriate claim file documentation and accurate claim coding.Communicate claim activity regularly to any relevant internal and external stakeholders including injured workers, policyholders, medical providers, and carriers when appropriate.Timely prepare state filings within the state statutory regulations.
Calculate the average weekly wage and indemnity benefits owed.Ensure all benefits are paid timely and in accordance with jurisdictional requirements.Exercise accurate discernment and decision-making to analyze claims exposure and to plan and document the proper course of action to move the claim to resolution.
Coordinate vendor utilization while considering claim cost containment techniques and outcomes including but not limited to nurse case management, surveillance, etc.
Manage claim recoveries including but not limited to Second Injury Fund, subrogation, and Medicare offsets.Notify management of large loss exposure, denial, coverage disputes, subrogation potential, or other matters requiring escalation or collaboration.Maintain knowledge of jurisdictional requirements and applicable case law for each State including appropriate licensure and continuing education requirements.
Perform other duties as requested and assigned.COMPETENCIESIn-depth knowledge of workers’ compensation insurance principles and laws, as well as cost containment principlesStrong analytical, critical thinking, and problem-solving skillsDetail-oriented with the ability to work in a team environmentExcellent customer service, written and verbal communication skills Ability to prioritize and balance multiple projects simultaneouslyResults-driven, proactive, and able to work autonomously Ability to exercise discretion and independent judgmentSUPERVISORY RESPONSIBILITYThis position will not have supervisory responsibilities.
Requirements:TECHNICAL SKILLS REQUIREDProficient in Microsoft Office Suite, PDF Professional, G Suite, or similar software.WORK ENVIRONMENT & PHYSICAL DEMANDSUnless fully remote, this position operates in a professional office setting and routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines.
This is largely a sedentary role with prolonged periods of sitting at a desk and working on a computer.
However, some filing is necessary and may require the ability to lift files, open filing cabinets and bend or stand on a stool as necessary.POSITION & EXPECTED HOURSThis is a full-time, salaried exempt position.
Typical work hours and days are Monday through Friday, from 8:00 am to 5:00 pm.
Some flexibility in hours is allowed, however, the employee must be available during the ” Core” work hours of 9:30 am to 3:30 pm and must work 37.5 hours each week.TRAVELMinimal to no travel required.EDUCATION AND EXPERIENCEBachelor’s degree from an accredited college or university preferredAt least 1-4 years of experience in workers’ compensation claims experience is preferred.A combination of education and experience in a TPA or brokerage environment will be considered Must be Bi-lingual (Spanish)State adjuster’s licenses as requiredBENEFITSMedical, Dental, and Vision 401k MatchingHSA Contribution4 Weeks’ Paid Maternity LeaveHybrid/Remote/On-site Work37.5 Hour Work WeekAbout MethodMethod Workers’ Compensation is a portfolio of workers’ comp companies with the same mission: minimizing the human and financial cost of workplace injuries.
We mitigate workplace injuries and deliver exceptional healthcare outcomes for injured workers, expediting a return to work, preserving families’ livelihoods, and enhancing employers’ productivity.
We maintain in-house expertise in claims management, medical bill review, underwriting and loss prevention for high-hazard, high-mod, and mid-market risks.
From submission to claim, we’re there every step of the way, improving outcomes for everyone involved.
Method currently operates in all non-monopolistic states.PM21PI187920295