Triangle Insurance is Now Hiring - Full-Time Claims Analyst/Adjuster - with an option to work out of the Little Rock AR or Enid, OK office. Join our team and immerse yourself in a highly respected organization cemented by a dynamic culture rich with ingenuity and integrity. Our generous compensation packet includes competitive pay, paid time off, exceptional benefits and dual retirement. Claims Analyst/Adjuster - Job Description Job Summary:
Responsible for processing workers' compensation claims where the injury or illness is limited to medical treatment. This role provides administrative and technical support to claims adjusters and other team members, ensuring efficient processing of claims. Duties/Responsibilities:Administrative: - Claim Setup and Data Entry. Receiving new claim information, inputting data into the claims management system, and creating claim files. This may involve gathering initial information from the insured or agent.
- Document Management. Organizing, scanning, and indexing claim-related documents (e.g., accident reports, photos, medical records, legal correspondence) and maintaining electronic and physical claim files.
- Communication. Answer phone calls and emails from insureds, agents, witnesses, and other parties involved in the claim, providing updates on claim status and answering general inquiries.
- Correspondence. Preparing and sending letters, emails, and other correspondence related to claims. This could include requests for information, reservation of rights letters, or settlement offers.
- Reporting. Generating reports on claim activity, such as open claims, closed claims, and reserve changes. Tracking key metrics and identifying trends.
- File Review. Reviewing claim files for completeness and accuracy. Ensuring all necessary documents are present and that information is correctly recorded.
- Support to Adjusters. Assisting claims adjusters with various tasks.
- System Updates. Maintaining accurate and up-to-date information in the claims management system.
- Other Administrative Tasks. Performing general administrative duties, such as filing, copying, and ordering supplies. Any others as assigned.
Claims Handling (Workers Compensation Medical Only):
- Claim Intake and Setup. Receiving and processing First Reports of Injury (FROI) or other claim notifications, setting up new claims in the system, and verifying employee information and employer coverage.
- Medical Treatment Authorization. Reviewing medical treatment requests from healthcare providers to determine if they are reasonable, necessary, and related to the work injury. This often involves applying established medical guidelines and utilizing review protocols.
- Medical Bill Review. Analyzing medical bills for accuracy, appropriate coding (CPT, HCPCS), and compliance with fee schedules or negotiated rates. Identifying and resolving discrepancies.
- Communication. Communicating with healthcare providers to obtain medical records, clarify treatment plans, and discuss billing issues, also with employers and claimants.
- Claim Investigation (Limited). While the focus is medical, some investigation may be needed to confirm the injury occurred at work and is compensable under workers' compensation laws. This might involve gathering information about accidents or incident.
- Coordination of Care. Working with case managers or nurse case managers (if involved) to ensure appropriate medical care is provided and to facilitate a timely return to work (if applicable, though less common in medical-only claims).
- Payment Processing. Authorize and process payments to medical providers for authorized treatment.
- Claim Closure. Closing medical-only claims once treatment is complete and all bills have been processed.
- Compliance. Adhering to workers' compensation regulations, state-specific guidelines, and company policies.
- Documentation. Maintaining accurate and detailed records of all claim-related activities, including medical records, billing information, and communication logs.
- Subrogation. Identify and respond to any recovery potential.
Additional Responsibilities: - Identify and escalate potential fraud.
- Provide excellent customer service to all stakeholders.
- Regular and sustained attendance.
- Perform other duties as assigned.
Required Skills/Abilities:
- Excellent interpersonal and customer service skills.
- Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence.
- Effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
- Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage and to draw and interpret bar graphs.
- Effective organizational skills and attention to detail.
- Excellent time management skills with a proven ability to meet deadlines.
- Proficient with Microsoft Office Suite, Teams, and other internal operating systems.
Education – Licensing - Certifications - Experience:
- A bachelor's degree with business experience is preferred, or two (2) or more years of past insurance claims experience may be substituted.
- High School Diploma required.
- Adjusters' license in claims is required within the first year of employment.
Physical & Work Requirements:
The physical demands described here represent those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand, walk, sit, use hands and fingers to grasp, handle, or feel, and reach with hands and arms. The employee must occasionally lift and move up to 10 pounds. Specific vision abilities required by this job include close vision and distance vision.
The work environment for this position is normally a climate-controlled environment with moderate noise levels.
Safety Sensitive Position (Yes/No): NO
Safety-sensitive positions are defined as jobs or positions where the employees holding these positions have the responsibility for their own safety or other people's safety. It would be particularly dangerous if:
Such an employee is using drugs or alcohol while on the job. This could include legal or illegal controlled substances.
Employees are unable to provide their complete time and attention in performing the sensitive or hazardous tasks of the position.
Physical limitations of the job could result in injury or harm to employees or others.
DISCLAIMER
This Job Description indicates the general nature and level of work expected and does not imply a contract of employment. Employment is at-will. It is not designed to cover every activity, duty, or responsibility required of the employee. Management may, at its discretion, assign or reassign duties and responsibilities to this job at any time.
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