Workers' Compensation Medical Only Adjuster

Description

Job Title:  Workers’ Compensation Medical Only Adjuster 

Department:  Workers’ Compensation                                                             

Reports to: Workers' Compensation Claims Manager

Position Summary:

This is an office position responsible for the adjudication of medical only workers’ compensation claims, assigned by our clientele, in accordance with the New Mexico Workers’ Compensation Statute, governing rules and regulations, related case law and client and company procedures. New loss assignments are client specific, based on case complexity.  

Essential Functions:

• Investigate the claim and verify information to determine cause of injury/accident history; determination of compensability. Interviewing employer, employees, witnesses; coordination of medical treatment and will learn skills necessary to take a recorded statement.
• Must possess the ability to maintain accurate and complete claim documentation in CMS and or other client proprietary claim systems utilized. This position is responsible for reporting to clients per their specific guidelines.  Must show proficiency in utilizing a diary system and keep open files maintained on that diary.
• Has to have strong analytical skills for proper posting and monitoring of reserves for medical exposure pursuant to client instructions and or company best practice standards. 
• Timely review and payment of medical bills per NM Statutory requirements. Must be familiar with related case law and the ability to interpret and comply with client and company standards, policies and procedures.
• Must make required State filings through EDI. Ensure that proper outside vendors referrals are made and properly justified. Knowledge of medical terminology to evaluate and interpret medical records / reports ensuring treatment is related to the reported injury. Identify strategies to close claim files timely or to transfer claims to a lost time adjuster for management of indemnity and more complex medical issues.
• This position is also be an introduction to future disability payouts; finite periods of disability indemnity benefits and long term medical maintenance supervision.  
• Attend seminars, education opportunities and industry functions as a representative of the company.

Requirements

Education:    

High school diploma required. Bachelor’s degree from an accredited college or university preferred.

A minimum of two years the insurance industry or similar experience handling claims. Additional relevant experience considered in lieu of education.

This is an entry level training position, however it is preferred that the applicant have some knowledge and recognition of a workers’ compensation claim. 

Required Skills/Abilities:

• Demonstrate expertise evaluating and workers’ compensation medical claims required.
• Demonstrate beginning to intermediate knowledge of medical issues and injury occurrences.
• Possess superior customer service and conflict resolution skills.
• Strong presentation and negotiation skills. 
• Attention to detail and accuracy.
• Excellent oral and written communication skills. 
• Ability to build and maintain relationships with internal and external Clients.
• Technologically savvy, able to navigate current computer system; proprietary client systems and internet programs with speed and efficiency. 
• Excellent organization skills which includes ability to multi-task; prioritize and maintain a diary / calendar system.
• Must be a self-starter with the ability to work independently and as part of a team.

Specialized Knowledge, Licenses, etc.:

Demonstrated proficiency in:

• Desire to pursue professional designations, such as AIC, ARM, CPCU (Preferred but not required).
• Ability to obtain New Mexico Adjuster License (Required)
• MS Word and Outlook (Required) MS Excel and PowerPoint (Preferred)
• Adobe (Preferred)