Workers' Compensation Claims Adjuster II

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, deductibles

• Initiates 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 parties

• Secures appropriate video, pertinent evidence, and recommends hiring a field investigation or expert when appropriate

• Documents 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 history

• Sets and monitors timely, adequate reserves in compliance with the company reserving philosophy and methodology throughout the life of the claim

• Secures and reviews all necessary official reports, claim forms and documents, providing summaries of them to the claim file

• Reviews bills, invoices, and receipts, including legal and litigation related expenses, for accuracy and appropriateness

• Notifies 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 claims  

• Drafts and sends investigation letters and denial letters upon Supervisor approval 

• Provides prompt, detailed responses to agents, insureds, and claimants on the status of claims 

• Communicates with insured, claimants, and attorneys to negotiate the settlement of claims  

• Prepares settlement evaluations, negotiation ranges and target settlement numbers prior to negotiation

• Determines and negotiates settlement amounts for resolution within assigned authority limits. Makes recommendations to management for settlement amounts outside of authority limits 

• Assists claims team members in handling of claims

• Maintains continuing education credits and licenses current as required by jurisdiction

• Submits referrals to the Special Investigation, Subrogation, external Medical Management, and internal Medical Review Units as Appropriate  

• Markets On Call Nurse (OCN), Return to Work (RTW), and Select Preferred Provider (SPP) programs to insured’s and identifies non-use for corrective measures

• Prepares risk alerts for Underwriting and Risk Improvement

Education & Experience:

• Bachelor’s degree or equivalent relevant experience

• Three years of workers compensation claims adjusting experience or related experience

• Attainment of all applicable state licenses within six months of hire

• Relevant insurance designations preferred

Knowledge, Skills, and Abilities:

• Strong knowledge of the theory and practice of the claim function

• Good knowledge of insurance contracts, medical terminology and substantive and procedural laws

• Ability to adhere to high standards of professional conduct and code of ethics

• Strong knowledge of computers and claims systems

• Strong written and verbal communication skills

• Excellent customer service skills

• Solid investigative and problem-solving abilities

• Strong organizational abilities and empathetic interpersonal skills

• 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 $69,643.41 - $89,430.74. The hiring range for other locations may vary.