EMC Insurance
Workers' Compensation Claims Adjuster I
EMC Insurance, Iowa City, Iowa, United States, 52245
At EMC, you'll put your skills to good use as an important member of our team. You can count on gaining valuable experience while contributing to the company's success. EMC strives to hire and retain the best people by engaging, developing and rewarding employees.
**This position is eligible to work from home anywhere in the United States**
Summary:
Exercises independent judgment in the investigation, evaluation, negotiation, and disposition of workers' compensation claims, within limitations of authority outlined in the Claims Guide. Communicates with insureds, agents, and experts regarding coverage and claim status or questions.
Essential Functions:
Reviews the claim notice, contracts, state statutes, and policies to verify the appropriate coverage, deductibles, jurisdiction and compensability.Initiates timely contact with insureds and claimants to explain the claims processObtains statements from insureds, injured workers, witnesses, and any other pertinent parties as appropriateDocuments claim activities, reserve analysis, summaries of reports in the claim systemSets timely, adequate reserves in compliance with the company reserving philosophy and methodologyIdentifies, investigates, and proactively pursues opportunities for recovery and subrogationResearches medical treatment and diagnosis to gain understanding of claimant's injury and medical historyNotifies all parties involved that legally require notice per jurisdictional requirementsSecures and reviews all necessary official reports, claim forms, video and documentsReviews medical bills, invoices, and receipts for appropriateness and accuracyNotifies the Claims Supervisor of claims requiring reassignment to a more appropriate level of claim handlerGathers payment data to calculate wage benefits due and pays accordingly through proper payment channelsContinues to monitor wage loss data for changes such as overtime, light duty, child-support liens, seasonal and contractual employment, raises, and annual state legislative reviews that impact wage reimbursement and adjustmentsCoordinates return to work with medical providers, insured and claimantsCoordinates appropriate medical care, including use of appropriate cost containment techniques and resourcesMaintains accurate and timely diaries on all files to bring claims to resolutionAssists with marketing and agency duties as neededDrafts independent medical exam (IME) and denial letters with supervisor oversight when appropriatePrepares settlement evaluations, negotiation ranges and target settlement numbers prior to negotiationInvestigates and resolves questions of compensability and communicates with all relevant parties to resolve coverage issues in a timely mannerWorks with attorneys, attending mediations, settlement conferences etc. to resolve claimsAssists claims team members as needed in handling of claimsSubmits referrals to the Special Investigation, Subrogation, external Medical Management, and internal Medical Review Units as AppropriateMarkets On Call Nurse (OCN), Return to Work (RTW), and Select Preferred Provider (SPP) programs to insured's and identifies non-use for corrective measuresPrepares risk alerts for Underwriting and Risk ImprovementEducation & Experience:
Bachelor's degree or equivalent relevant experienceOne year of workers' compensation claims adjusting experience or related experienceAttainment of all applicable state licenses within one year of hireRelevant insurance designations preferredKnowledge, Skills & Abilities:
Working knowledge of the theory and practice of the claim functionGood knowledge of insurance contracts, medical terminology and substantive and procedural lawsAbility to adhere to high standards of professional conduct and code of ethicsStrong knowledge of computers and claims systemsStrong organizational and written and verbal communication skillsGood investigative and problem-solving abilitiesOccasional travel required; a valid driver's license with an acceptable motor vehicle report per company standards required if driving
Per the Colorado Equal Pay for Equal Work Act, the hiring range for this position for Colorado-based team members is $58,618.44 - $75,262.27. The hiring range for other locations may vary.
Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.
All of our locations are tobacco free including in company vehicles.
**This position is eligible to work from home anywhere in the United States**
Summary:
Exercises independent judgment in the investigation, evaluation, negotiation, and disposition of workers' compensation claims, within limitations of authority outlined in the Claims Guide. Communicates with insureds, agents, and experts regarding coverage and claim status or questions.
Essential Functions:
Reviews the claim notice, contracts, state statutes, and policies to verify the appropriate coverage, deductibles, jurisdiction and compensability.Initiates timely contact with insureds and claimants to explain the claims processObtains statements from insureds, injured workers, witnesses, and any other pertinent parties as appropriateDocuments claim activities, reserve analysis, summaries of reports in the claim systemSets timely, adequate reserves in compliance with the company reserving philosophy and methodologyIdentifies, investigates, and proactively pursues opportunities for recovery and subrogationResearches medical treatment and diagnosis to gain understanding of claimant's injury and medical historyNotifies all parties involved that legally require notice per jurisdictional requirementsSecures and reviews all necessary official reports, claim forms, video and documentsReviews medical bills, invoices, and receipts for appropriateness and accuracyNotifies the Claims Supervisor of claims requiring reassignment to a more appropriate level of claim handlerGathers payment data to calculate wage benefits due and pays accordingly through proper payment channelsContinues to monitor wage loss data for changes such as overtime, light duty, child-support liens, seasonal and contractual employment, raises, and annual state legislative reviews that impact wage reimbursement and adjustmentsCoordinates return to work with medical providers, insured and claimantsCoordinates appropriate medical care, including use of appropriate cost containment techniques and resourcesMaintains accurate and timely diaries on all files to bring claims to resolutionAssists with marketing and agency duties as neededDrafts independent medical exam (IME) and denial letters with supervisor oversight when appropriatePrepares settlement evaluations, negotiation ranges and target settlement numbers prior to negotiationInvestigates and resolves questions of compensability and communicates with all relevant parties to resolve coverage issues in a timely mannerWorks with attorneys, attending mediations, settlement conferences etc. to resolve claimsAssists claims team members as needed in handling of claimsSubmits referrals to the Special Investigation, Subrogation, external Medical Management, and internal Medical Review Units as AppropriateMarkets On Call Nurse (OCN), Return to Work (RTW), and Select Preferred Provider (SPP) programs to insured's and identifies non-use for corrective measuresPrepares risk alerts for Underwriting and Risk ImprovementEducation & Experience:
Bachelor's degree or equivalent relevant experienceOne year of workers' compensation claims adjusting experience or related experienceAttainment of all applicable state licenses within one year of hireRelevant insurance designations preferredKnowledge, Skills & Abilities:
Working knowledge of the theory and practice of the claim functionGood knowledge of insurance contracts, medical terminology and substantive and procedural lawsAbility to adhere to high standards of professional conduct and code of ethicsStrong knowledge of computers and claims systemsStrong organizational and written and verbal communication skillsGood investigative and problem-solving abilitiesOccasional travel required; a valid driver's license with an acceptable motor vehicle report per company standards required if driving
Per the Colorado Equal Pay for Equal Work Act, the hiring range for this position for Colorado-based team members is $58,618.44 - $75,262.27. The hiring range for other locations may vary.
Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.
All of our locations are tobacco free including in company vehicles.