Senior Claims Adjuster - Workers Compensation

United States·San DiegoExemptsenior

OtherClaims Adjuster

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Requirements Summary

BHHC has an immediate opportunity for experienced Workers Compensation Claims Professionals. This position requires a self-starter who can work under minimum direction, can achieve defined results, and willing to accept ownership for their work…

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WHAT WE'RE LOOKING FOR

The Senior Claims Professional is responsible for the management of a complex caseload of workers compensation indemnity claims from inception to resolution. This individual works under general supervision with elevated reserve and settlement parameters and encouraged to participate in special projects focused on process efficiency.

Helps injured workers achieve rapid and full medical recovery and early, safe return to work through effective, efficient and timely medical treatment and return-to-work support.

Effectively communicates with injured workers and employers. Demonstrates expertise and empathy, building trust and moving the claim forward, including timely three-point contacts on all new losses.

Manages claims with an outcome-based and resolution focus. Demonstrates highly effective strategic plans for future handling that are well outlined in plans of action and followed through in a timely fashion.

Demonstrates effective decision making in compensability determinations and benefit authorizations (within designated authority parameters). Proactively utilizes resources such as Medical Management, SIU, Subrogation, Recovery and Legal to ensure accurate determinations in compensability, causal relationship, appropriate medical treatment, and to achieve favorable outcomes.

Prepares and maintains timely, accurate reserves on all claims for expected future costs of medical treatment, benefits and other elements in accordance with Claims Handling Guidelines. Ensures reserves are escalated and approved as appropriate. Ensures there is appropriate reserve documentation in the file.

Prepares timely and accurate settlement recommendations (within designated authority parameters) and effectively negotiates the settlement of claims.

Reduces fraud through early identification and escalation.

Effectively manages defense attorneys. Demonstrates excellence in litigation management by being prepared for hearings in a timely manner and appropriately considering exposures, settlement options, and other legal issues.

Reviews and approves vocational rehabilitation plans.

Effectively manages vendors and providers. Identifies need for assignment and removal of vendors and makes effective use of vendor expertise while maintaining ownership of the claim.

Demonstrates expertise in technical aspects of claim management. Works with Medicare Set Asides, Structured Settlements and/or Part B issues.

Maintains effective relationships with internal and external service partners, including participation in periodic telephonic claims reviews.

Calculates and pays benefits in accordance with the law. Ensures that the claim as a whole is managed in accordance with all legal requirements including the issuance of appropriate notices and filings.

EDUCATION: Minimum of a High School diploma required or equivalent certificate required; Bachelor's degree from four-year College or university preferred.

DESIGNATION: Designated as a Claims Adjuster or Experienced Claims Adjuster per the California Code of Regulations and has completed the minimum required continuing education credits to adjust workers compensation claims for the State of California; Self-Insured certification a plus.

EXPERIENCE: Minimum of eight years of indemnity adjusting experience managing large and/or complex claims and accounts within a workers’ compensation carrier required

Maintains qualifying educational criteria to adjust workers’ compensation claims for the State of California; Self-Insured certification preferred.

Inquisitive, critical thinker; agile learner with adaptive, smart time management skills

To perform this job successfully, an individual should be proficient in the Microsoft Office Suite of applications and be proficient, or able to become proficient, on applicable databases, systems, and vendor software programs.

Work-Life Balance

Work From Home Program (up to 2 days per week)

Reasonable caseload with in-house Medical Management support (UR, Med Bill Review, Resource Nurses); In-house Claims Assistant support

Free On-Site Fitness Facility

Free On-Site Garage Parking

Paid Time Off

Paid Holidays

Retirements Savings Match

Group Health Insurance (Medical, Dental, and Vision)

Life and AD&D Insurance

Long Term Disability Insurance

Accident and Critical Illness Insurance