EMC Insurance
Workers' Compensation Claims Adjuster II
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**
Exercises independent judgment in the investigation, evaluation, negotiation, and disposition of moderately complex 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 and evaluates the claim notice, lawsuits, contracts, state statutes, and policies to verify the appropriate coverage, deductiblesInitiates timely contact with insureds and injured worker to explain the claims process, and begin investigation to determine compensability, and appropriate jurisdiction for the correct state statues.Obtains statements as appropriate from insured, injured worker, witnesses, and all other pertinent partiesSecures appropriate video, pertinent evidence, and recommends hiring a field investigation or expert when appropriateDocuments claim activities, reserve analysis, summaries of reports in the claim system including Medicare (MSP) modules in the claims system.Research medical treatment and diagnosis to gain understanding of claimant's injury and medical historySets and monitors timely, adequate reserves in compliance with the company reserving philosophy and methodology throughout the life of the claimSecures and reviews all necessary official reports, claim forms and documents, providing summaries of them to the claim fileReviews bills, invoices, and receipts, including legal and litigation related expenses, for accuracy and appropriatenessNotifies all parties involved that legally require appropriate notice including but not limited to the state and other carriers as necessary.Resolves questions of coverage, liability, and the value of the claims and communicates with insureds and claimants to resolve claimsDrafts and sends investigation letters and denial letters upon Supervisor approvalProvides prompt, detailed responses to agents, insureds, and claimants on the status of claimsCommunicates with insured, claimants, and attorneys to negotiate the settlement of claimsPrepares settlement evaluations, negotiation ranges and target settlement numbers prior to negotiationDetermines and negotiates settlement amounts for resolution within assigned authority limits. Makes recommendations to management for settlement amounts outside of authority limitsAssists claims team members in handling of claimsMaintains continuing education credits and licenses current as required by jurisdictionSubmits 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 experienceThree years of workers compensation claims adjusting experience or related experienceAttainment of all applicable state licenses within six months of hireRelevant insurance designations preferredKnowledge, Skills, and Abilities:
Strong 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 written and verbal communication skillsExcellent customer service skillsSolid investigative and problem-solving abilitiesStrong organizational abilities and empathetic interpersonal skillsTravel 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 $69,643.41 - $89,430.74. 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**
Exercises independent judgment in the investigation, evaluation, negotiation, and disposition of moderately complex 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 and evaluates the claim notice, lawsuits, contracts, state statutes, and policies to verify the appropriate coverage, deductiblesInitiates timely contact with insureds and injured worker to explain the claims process, and begin investigation to determine compensability, and appropriate jurisdiction for the correct state statues.Obtains statements as appropriate from insured, injured worker, witnesses, and all other pertinent partiesSecures appropriate video, pertinent evidence, and recommends hiring a field investigation or expert when appropriateDocuments claim activities, reserve analysis, summaries of reports in the claim system including Medicare (MSP) modules in the claims system.Research medical treatment and diagnosis to gain understanding of claimant's injury and medical historySets and monitors timely, adequate reserves in compliance with the company reserving philosophy and methodology throughout the life of the claimSecures and reviews all necessary official reports, claim forms and documents, providing summaries of them to the claim fileReviews bills, invoices, and receipts, including legal and litigation related expenses, for accuracy and appropriatenessNotifies all parties involved that legally require appropriate notice including but not limited to the state and other carriers as necessary.Resolves questions of coverage, liability, and the value of the claims and communicates with insureds and claimants to resolve claimsDrafts and sends investigation letters and denial letters upon Supervisor approvalProvides prompt, detailed responses to agents, insureds, and claimants on the status of claimsCommunicates with insured, claimants, and attorneys to negotiate the settlement of claimsPrepares settlement evaluations, negotiation ranges and target settlement numbers prior to negotiationDetermines and negotiates settlement amounts for resolution within assigned authority limits. Makes recommendations to management for settlement amounts outside of authority limitsAssists claims team members in handling of claimsMaintains continuing education credits and licenses current as required by jurisdictionSubmits 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 experienceThree years of workers compensation claims adjusting experience or related experienceAttainment of all applicable state licenses within six months of hireRelevant insurance designations preferredKnowledge, Skills, and Abilities:
Strong 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 written and verbal communication skillsExcellent customer service skillsSolid investigative and problem-solving abilitiesStrong organizational abilities and empathetic interpersonal skillsTravel 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 $69,643.41 - $89,430.74. 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.