EMPLOYERS MO Claims Adjuster in Maitland, Florida
MO Claims Adjuster
As a dynamic, fast-growing provider of workers' compensation insurance and services, we are seeking a goal-oriented individual willing to put their ideas to work!
We offer a positive, challenging work environment, combined with an opportunity to build your career as you help us grow our business, in innovative and imaginative ways that are uniquely EMPLOYERS®!
Headquartered in Reno, Nevada, EMPLOYERS attributes its long-standing success to its most valuable resource, our employees across the United States. EMPLOYERS is known for the quality service and expertise we provide to our clients, and the exemplary work environment we provide for our employees.
We live and breathe our core values: Integrity, Customer Focus, Collaboration, Initiative, Accountability, Innovation, and Personal Fulfillment. These are the pillars that support how we do business with our clients as well as how we treat each other!
At EMPLOYERS, you’ll discover an energetic environment that inspires top achievement. As “America’s small business insurance specialist”, we have the resources, a solid reputation and an expanding nationwide identity to enrich your work/life and enhance your career.
Summary: Perform duties to process claims involving medical benefits and/or minor indemnity; determine compensability, set reserves, and process payments, within the limits of standard or accepted practice. Work will be performed under direct supervision within a computer-based environment. Continually increases overall general knowledge.
Essential Functions: 1. Receive and review information related to new claims involving no or minimal lost time from work. May manage a small amount of claims that are more complex. Communicate with injured workers, employers, and medical providers. Determine compensability based on contact information, accident reports, and statutes. Understands and adheres to Claims Best Practices.2. Assigns case to contactor if applicable for investigation of circumstances when compensability is questionable.3. Accurately calculates and pays appropriate benefits in a timely manner.4. Set up file diaries, manage medical treatment, establish reserves up to authority level, submit reserve recommendations of higher level for authorization, and file required State forms. Document follow-up care, actions taken to settle claim and other claim related activity.5. Review case facts to identify possible fraud or abuse throughout course of claim.6. Follow up with contacts to medical provider and insured employer regarding injured workers’ progress. Review reserves and adjust as required. Support the process by scheduling medical or testing appointments and providing authorizations. Demonstrate sound medical management skills and aggressive claims handling, proactively pursuing return to work.7. Develops, monitors, and adheres to a written plan of action to facilitate ongoing claim management.8. Manage legal issues under the direct guidance of claims adjuster or supervisor that can be adjudicated without the use of a defense attorney. May direct legal strategy and participate in preparation of case for next level(s) of litigation. 9. Review and respond to incoming mail, emails, telephone calls and fax transmissions from providers and injured worker, related to caseload. Take actions required to respond within regulations and policy.10. Review and approve or deny medical bills.11. Conduct business at all times with the highest standards of personal, professional and ethical conduct.12. Ensures timely compliance with all policy and procedures as well as jurisdictional statutes.13. Established and maintains ongoing professional communications with all appropriate parties, internal and external.14. Maintains professional and technical knowledge by attending employer sponsored training classes.15. Visits employers relative to claims management, as required.16. All other duties as assigned or as situation dictates.
Supervisory Responsibilities:1. None
Required Minimum Qualifications / Knowledge, Skills & Abilities:• Excellent written and oral communication, customer service and telephone skills• Demonstrated knowledge of MS Office software• Demonstrated ability to understand and adhere to statutes, regulations and company policies and practices.• Demonstrated skill in working independently with little direction, multi-tasking skills, determine the relative importance of each, adhere to deadlines, and complete assignments accordingly.• Ability to maintain confidentiality.• If State Certification is required, must meet certification within state mandated time frame.• Must have High School Diploma or GED equivalent.
Preferred Qualifications / Knowledge, Skills & Abilities:• Minimum 1 year experience working in workers’ compensation environment or an equivalent combination of education and qualifying experience.• Working knowledge of medical terminology• AIC, ARM, or CPCU certification
Working Conditions:• Performs duties in an office environment consisting of computer equipment, phones, consistent temperature and background noise.• Occasionally fluctuations in pace and priority will occur.• The temperature is controlled by heating and air components and set to create a reasonable environment for all employees.
Physical Demands:• While performing the duties of this job the employee is regularly required to sit, stand, use hands to finger, handle, or feel; reach with hands and arms and talk or hear.• Frequently required to lift, push, pull, twist or otherwise handle items of 10- 25 pounds.• The vision requirements include: close vision, peripheral, depth, far and near sightedness.
Tools and Equipment:• Computer and peripherals, standard and customized software, and usual office machines.