Senior Claims Adjuster - Workers Compensation

Lodestar Claims & Risk Services; Arlington (VA); Remote; USD 70,000 - 100,000; Full time

Job summary

Lodestar Claims & Risk Services seeks a Sr Claims Specialist to independently investigate and resolve complex workers’ compensation claims. You will determine coverage, reserves, and subrogation potential while working with Lodestar nurses on return-to-work plans.

The role requires 3–5 years of lost-time WC experience, an insurance background, and ability to obtain licenses within 90 days in mandated states. Strong communication and analytical skills are essential.

Qualifications

• 3-5 years' experience handling lost time workers compensation claims; VA jurisdiction experience preferred.
• Bachelor’s degree or four or more years of equivalent work experience in an insurance related industry required.
• Active license required or ability to obtain within 90 days in mandated states.
• Familiarity with medical terminology and/or Workers' Compensation.
• Strong organizational skills with the ability to work independently and on multiple tasks.

Responsibilities

• Promptly investigate all assigned claims with minimal supervision, including complex claims
• Determine coverage, compensability, subrogation potential, and second injury fund applicability
• Alert supervisor or SIU to potentially suspicious claims
• Ensure timely denial or payment of benefits per jurisdictional requirements
• Establish and adjust reserves with documented rationale
• Negotiate settlements with client approval
• Develop action plans for case resolution including medical/disability management, litigation, and disposition
• Collaborate with Lodestar nurse professionals on return-to-work strategies
• Select and manage vendors to balance costs and outcomes
• Maintain knowledge of jurisdictional requirements and applicable case law
• Communicate effectively with internal/external parties
• Provide high level customer service during reviews and meetings
• Authorize treatment per statutes and Lodestar policies
• Suggest panel provider information for states served
• Adhere to Code of Business Conduct and Ethics and compliance policies

Skills

Attention to detail

Strong communication

Organizational skills

Critical thinking

Time management

Team collaboration

Education

Bachelor's degree or 4+ years in insurance

Tools

MS Word

Excel

PowerPoint

Job description

#4861

Multiple Locations

Location

PMA Remote-PMAR

Position

Sr Claims Spec

External Description

As a member of our claims team, utilize your knowledge of Workers Compensation to independently investigate, evaluate and resolve assigned claims of a more complex nature in order to achieve appropriate outcomes. In this position you will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statues, policy provisions, and company guidelines.

Responsibilities:

• Promptly investigate all assigned claims with minimal supervision, including those of a more complex nature
• Determine coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)
• Alert Supervisor and Special Investigations Unit to potentially suspect claims
• Ensure timely denial or payment of benefits in accordance with jurisdictional requirements
• Establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure
• Negotiate claims settlements with client approval
• Establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
• Work collaboratively with Lodestar nurse professionals to develop and execute return to work strategies
• Select and manage service vendors to achieve appropriate balance between allocated expense and loss outcome
• Maintain a working knowledge of jurisdictional requirements and applicable case law for each state serviced
• Demonstrate technical proficiency through timely, consistent execution of best claim practices
• Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
• Provide a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
• Authorize treatment based on the practiced protocols established by statute or the Lodestar Managed Care department
• Assist Lodestar clients by suggesting panel provider information in accordance with applicable state statutes.
• Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

Requirements

Requirements:

• At least 3-5 years' experience handling lost time workers compensation claims required; past experience with VA jurisdiction is required
• Bachelor's degree, or four or more years of equivalent work experience required in an insurance related industry required
• Active license required or ability to obtain license within 90 days of employment in mandated states.
• Familiarity with medical terminology and/or Workers' Compensation
• Strong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneously
• Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
• Strong verbal, written communication skills and customer service skills
• Computer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint.
• Ability to travel for business purposes, approximately less than 10%.

This Company is an Equal Opportunity Employer, and does not discriminate on the basis of race, gender, ethnicity, religion, national origin, age, disability, veteran status, or on any other basis prohibited by law. Information on race, gender and national origin will only be used for statistical and recordkeeping purposes, and will not be used in making any employment decisions. All information provided will be kept separate from your expression of interest. Providing this information is strictly voluntary, and you will not be subjected to any adverse action or treatment if you choose not to provide this information. If you do not choose to answer these questions, we ask that you select "Decline to Identify" for each question. Thank you for your voluntary cooperation.