Workers Compensation Claims Examiner (PA & NJ Jurisdictions)

Job Title: Sr. Workers Compensation Claims Examiner

POSITION SUMMARY: Under minimal supervision manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines. 

DUTIES AND RESPONSIBILITIES:

• Adjuster will work a hybrid scheduled of two (2) days per week in-office.
• Effectively manages a caseload of 125 to 150 workers’ compensation files, including very complex claims.*
• Jurisdiction is PA, NJ*
• Initiates and conducts investigation in a timely manner.*
• Determines compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines.*
• Manages medical treatment and medical billing, authorizing as appropriate.*
• Refers cases to outside defense counsel.  Directs and manages as appropriate.* 
• Communicates with claimants, providers and vendors regarding claims issues.*
• Computes and set reserves within Company guidelines.  Limits are larger than those allowed for Claims Adjuster I and Claims Adjuster II.*
• Settles and/or finalize all claims and obtains authority as designated.*
• Maintains diary system for case review and documents file to reflect the status and work being performed on the file.*
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns.*
• Involves COMPANY loss control staff when appropriate.*
• Adheres to all Company policies and procedures.*
• Conducts file reviews independently.*
• Other duties as assigned.

* Essential job function.

QUALIFICATIONS REQUIRED:

Education/Experience:  Bachelor’s degree in related field (preferred); three (3) or more years related experience; or equivalent combination of education and experience.

Knowledge, Skills and Abilities:

• Technical knowledge of statutory regulations and medical terminology.
• Analytical skills.
• Excellent written and verbal communication skills, including ability to convey technical details to claimants, clients and staff.
• Ability to interact with persons at all levels in the business environment.
• Ability to independently and effectively manage very complex claims.
• Proficient in Word and Excel (preferred).

Other Qualifications: 

• No licenses required for the state of PA or NJ