This position will work full-time in our South & Mid-Atlantic office in Charlotte, North Carolina.
The Senior Claims Adjuster manages both routine and complex lost-time claims, including those with the potential to become serious and produce excessive costs. The Senior Claims Adjuster is responsible for the investigation, evaluation and determination of liability for work-related injury and disease claims following established guidelines to determine benefit eligibility. The Senior Claims Adjuster assesses expected losses and creates plans to minimize and/or eliminate risk factors in order to achieve effective claims outcomes. The position’s objective is to provide superior service in a cost- effective manner by executing best claim practices in an effort to eliminate unwarranted losses. The Senior Claims Adjuster also serves as a resource to Claims Adjusters.
The items listed are essential functions of the position unless otherwise stated
Methodically evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims to their most cost- effective conclusion.
Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.
Take recorded statements when necessary.
Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines.
Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels.
Establishes and maintains reserve values within authority limits, which accurately predict the loss reflecting the current known circumstances of the claim.
Actively develops the investigation of and pursuit of subrogation recoveries when possible.
Consults with supervisor or technical support staff on unusually complex claims.
Investigates, evaluates and negotiates settlements, applying technical knowledge and human relation skills to effect fair and prompt claim closure and to contribute to a reduced loss ratio.
Redirects the claim to the appropriate subject matter expert if the claim becomes significantly complex or presents significantly increasing financial exposure.
Applies effective protocols for medical management, litigation, fraud/abuse and recovery.
Effectively manages litigation in conjunction with legal counsel.
Presents claims and participates in discussion at team staffing.
Works collaboratively with injured employee, employer, outside counsel, health and rehabilitation professionals to manage the claims costs, promote quality medical care and timely return-to-work to achieve optimal cost-effective medical and vocational outcomes.
Along with the supervisor, Business Director and other claims staff, assists with or facilitates meetings with policyholders.
Nonessential function: other duties as assigned.
Knowledge in best claims practices and laws, court procedures, precedents and government regulations.
Ability to apply relevant information and individual judgment to determine whether events or processes comply with laws, regulations or standards.
Ability to recognize and analyze new or changing information that could affect the claims handling strategy and/or potential claims cost, and effectively use the information to manage the claim.
Demonstrated ability to work effectively in a team environment.
Demonstrated ability to use logic and sound reasoning to identify alternative solutions for problem-solving.
Demonstrated understanding of how to apply general rules to specific problems to produce workable solutions.
Ability to develop specific goals and plans to prioritize, organize, and accomplish work.
Demonstrated proficiency in evaluating the relative costs and benefits of potential actions to choose the most appropriate one.
Skilled in the use of computers and claims management systems and other typical business-related programs.
Demonstrated ability to develop and maintain strong, effective internal and external relationships.
Bachelor’s Degree from an accredited college or university is preferred.
Must have three years of experience in the insurance, claims investigation, legal, rehabilitation, or medical claims processing. Workers’ compensation claims experience preferred.
Must hold or be eligible to obtain a valid Adjuster’s License in applicable states*.
Must display skills and experience in industry’s best practices commensurate with BrickStreet’s published Best Practices for Claims Management.
Minimum of two years jurisdictional experience in Pennsylvania preferred.
Applications must be received by 5 PM Wednesday, September 10, 2014.
- Must pass the claims adjuster license exam(s) for applicable states within 60 days of being hired.
Headquartered in Charleston, W. Va., BrickStreet Mutual is the sole source of legally required workers compensation coverage for West...