Job Title: Claims Adjuster I

Department: Claims

Reports To: Claims Manager Supervisory Responsibility: NO

Position Summary: This position is responsible for the handling 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.

Essential Functions:

*Contact the injured worker, employer and medical provider as allowed by law to investigate, determine compensability and pay benefits.

*Documents all activities in the claim system, maintains the claim file. Verifies claim history and facts, takes recorded statements, and coordinates clinical information with Medical Case Managers.

*Contact injured worker, employer and all other necessary parties to gather the information necessary to determine coverage, compensability and benefits with supervision and approval of the Claims Manager or Claims Specialist.

*Provide positive service and communication with the worker and employer to develop the best possible working relationship. Identify and resolve any area of concern.

*Verify claim information including but not limited to: documentation of the claim history; taking recorded statements from workers and witnesses and coordination of clinical information with the Medical Case Manager.

*Upon determination of compensability: Set and monitor reserves according to company policies and the workersâ injury, issue benefit checks in accordance to statutory requirements, prepare case management and closure strategy with the Medical Case Manager.

*Knowledge of applicable state statutes, related case law and the ability to interpret and comply with company claims standards, policies and procedures.

*Provide concise, comprehensive written or verbal communication to all relevant parties.

*Make required filings and assure benefit payments within the established time frames and guidelines.

*Prepare, attend and present a majority of all mediations and hearings as determined by the Claims Manager or Litigation Manager. May represent the company at trial.

*Set, monitor and adjust reserves according to company procedures and the workersâ injury.

*Identify, investigate and subrogation potential.

*Make referral for legal representation according to company procedure.

*Determine case values and make settlement recommendations on claims above individual authority. Negotiate settlements with workers, their attorneys and third parties within individual authority and authority granted by a manager or the Director.

*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.

Other Functions:

*Types letters and prepares legal documents as necessary. Handles and returns phone calls promptly.

*Interprets and complies with applicable state statutes, laws, and company policies and procedures. Adheres to compliance regulations as established by the internal compliance department. Supports company policy procedures to advance company services and to maintain market leadership.

*Performs other duties as assigned.

Job Qualifications:

Education:
Bachelorâs Degree from an accredited college or university; and/or two to four years of related experience and/or training; or the equivalent combination of education and experience.

Experience:
A minimum of two years of workersâ compensation experience or demonstrated proficiency as determined by Claims Manager or Director.

Core Competencies:

General Skills:

*Ability to use office equipment including, but not limited to: fax, copier, computer, email, telephone, recording equipment, and other office equipment related to job.

*Demonstrated knowledge of Workersâ Compensation rules and regulations that apply in your area.

*Customer service orientated with excellent customer services skills.

*Ability to speak effectively to claimants, customers and co-workers by phone and in person.

*The ability to be task flexible.

*Works well independently as well as a team player.

*Ability to read and follow directions.

*Ability to read, interpret and apply information from a variety of sources such as manuals, professional publications and government regulations.

*Works to prevent disputes before they happen.

*Troubleshoots anticipated issues and recommends solution.

*Produces reasonable, clear, and grammatically correct written documents.

*Fully prepares for off-site meetings, hearings and presentations.

*Appears and conducts oneself in a professional manner at off-site meetings, hearings, and presentations.

*Demonstrates strong skills in reasoning and analysis.

*Keeps supervisor appropriately informed of progress in negotiations, and in anticipated problems.

*Maintains the highest professional standards related to the job.

*Good organizational, time management, and multitasking skills required.

*Ability to prioritize job activities as business needs demand.

*Demonstrated ability to prepare and analyze statistical data.

*Displays an understanding of the theoretical concepts related to job tasks.

*Demonstrates proficiency in basic math computations and algebra.

*Comprehensive mathematical and analytical skills

*Good understanding of privacy laws.

*Follows through on commitments; is reliable, conscientious and dependable.

Acquired/Specific Skills:

*Knowledge in the application of the New Mexico Workersâ Compensation Act, and governing rules and regulations.

*Must be able to set, monitor, and adjust reserves.

*Ability to participate and advocate for NMMGâs position during mediations and formal hearings with supervision.

Values and Mission:
Adhere to values and mission by demonstrating respect, integrity, honesty and stewardship and consistently exceeding the expectations of those we serve.

Positive Attitude:
Develop and maintain a positive work atmosphere by behaving and communicating in a manner so that you get along with clients, customers, co-workers and management.

Specialized Knowledge, Licenses, etc.:
Demonstrated proficiency in:

*Windows

*Excel

*Keyboarding

*E-mail

*State required adjusterâs license



Required Skills:
CLAIMS ADJUSTING, Lost Time Experience, Workers Compensation Experience, Good Computer Skills

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