Claims Adjuster I

Description

Job Title: Claims Adjuster I

Department: Claims

Reports To: Claims Manager

Position Summary:

This position is responsible for the adjudication of all assigned claims in accordance with the Act, governing rules and regulations, related case law and company procedures. Case complexity assignment is determined by the experience and qualifications of the adjuster. This position will demand quality claim handling expertise, Service Excellence standards, and timely indemnity, medical and expense benefit management.

Essential Functions:

• Evaluate, analyze and determine compensability, causation, offsets and exposures of basic workers compensation insurance claims in accordance with applicable law, corporate policy, best practice and prescribed authorities.
• Verify claim information including but not limited to: documentation of the claim history; taking recorded statements from workers and witnesses, identify subrogation opportunities, coordination of medical care. 
• Document all activities in the claim management system. Responsible for outside legal counsel assignments, RTW strategies with policyholders, implement medical case management strategies with nurse case managers and all other expert assignments.
• Upon determination of compensability: Set and monitor reserves according to company policies and the worker’s injury, issue benefit checks in accordance to statutory requirements, and demonstrate proficiency in the application of state statutes, related case law and to interpret and comply with company claims standards, policies and procedures. 
• Ensure the timely and accurate statutory/benefit payments within the established time frames and guidelines.
• Prepare and participate in mediation conferences and other authorized legal or regulatory proceedings before the regulatory agencies and courts of law.
• Maintain a diary on all open claims. Document all relevant information to provide a clear history of events and a proper audit trail. Set review dates based on claim complexity or standard review criteria.
• Detect and report reasonable suspicions of insurance fraud by claimants, medical or legal providers, policyholders or other individuals related to claims.
• Maintain claim records in compliance with applicable law, corporate policies and retention schedules.

Requirements

Job Qualifications:

Education:

Bachelor’s Degree from an accredited college or university.

Experience:

A minimum of one year of workers' compensation claims experience is preferred. Additional relevant experience considered in lieu of education.

Specialized Knowledge, Licenses, etc.:

Demonstrated proficiency in:

Related professional certifications preferred 

State required adjuster's license

Values and Mission:

Adhere to values and mission by demonstrating Service Excellence, Trust, Ownership, One team and Boldness in thought and action.

Positive Attitude:

Develops and maintains positive working relationships with team members, customers, co-workers and management by demonstrating effective communication and collaborative skills.

Working Conditions:

NEW MEXICO MUTUAL maintains general office conditions with light to moderate physical demands, with occasional lifting.  

Employees of NEW MEXICO MUTUAL adhere to all safety rules and regulations including building security.  

Employees participate in ensuring safe and efficient operating conditions that safeguard employees and facilities. 

NEW MEXICO MUTUAL maintains a drug free environment; drug testing prior to employment as well as upon a work related accident. 

Exposure to VDT screens.