Senior Workers Compensation Claims Adjuster

INSURICA, Inc.; Marble Falls (TX); Hybrid; USD 65,000 - 90,000; Full time

Job summary

INSURICA, Inc. in Texas is seeking a Workers’ Compensation Claims Adjuster to manage a caseload of approximately 150 open claims, applying best practices and regulatory standards to resolve matters efficiently.

You will investigate claims, interview injured workers, employers, and witnesses; determine causality and compensability; calculate benefits; coordinate return-to-work programs; and maintain precise records while mentoring junior staff to ensure compliance and quality across the team.

Qualifications

• Strong judgment and decision-making skills.
• Excellent organizational skills with attention to detail.
• Ability to communicate effectively in writing and orally.

Responsibilities

• Review initial workers’ compensation claims for accuracy and completeness.
• Investigate to determine validity and causality, interviewing employees, employers and witnesses.
• Determine approvals/denials and calculate benefits including medical expenses and wage replacement.
• Manage and monitor open claims; coordinate return-to-work programs and rehabilitation services.
• Maintain detailed records and prepare required reports to regulatory bodies.
• Identify subrogation opportunities and negotiate settlements.
• Mentor staff and ensure compliance with workers’ compensation laws.

Skills

Judgment

Decision-making

Communication

Interpersonal skills

Organizational skills

Education

Texas Workers’ Compensation Adjuster License

All-Lines Adjuster License

Tools

EDI knowledge

Job description

Job SummaryThe Worker’s Compensation Claims Adjuster will manage a caseload of approximately 150 open claims, exercising good judgment while resolving claims according to our established procedures and best claims practices, in accordance with statutory, regulatory, and ethics requirements.Job FunctionsReceive and review initial workers’ compensation claims, verifying the accuracy and completeness of claim forms and supporting documentationConduct thorough investigations to determine validity and extent of injury; interview the injured employee, employer(s) and any witnesses, as well as review medical reports, and accident reports to determine causality and compensabilityEffectively communicate with the injured worker, employer(s), medical professionals and legal representatives, as needed, providing ongoing updates and information to all parties involved in the claim processMake appropriate determinations on the approval or denial of claims, based on investigation findings and applicable laws; calculate correct benefit amounts, including medical expenses, wage replacement and any other necessary compensationManage and monitor open claims to ensure timely and appropriate processing; coordinate return-to-work programs and rehabilitation servicesEffectively maintain detailed and accurate records for each claim; prepare and submit required documentation and reports to regulatory bodiesTimely initiation, maintenance, and termination of temporary, impairment, and supplemental income benefitsIdentify and pursue subrogation when there is 3rd party negligence, and negotiate a fair settlement for all parties involvedAddress and resolve any disputes or issues that arise during the claim processServe as a subject matter expert and mentor to Workers’ Compensation Claims Adjuster staff members, providing guidance and direction, as needed, for difficult or unusual claims or client situationsReview all activities relating to the public, customers, and companies to avoid issues involving potential errors and omissions and ensure compliance with workers’ compensation laws and regulationsParticipate in seminars and other training to maintain required licenses and for knowledge and skill developmentAdditional ResponsibilitiesThis job description is intended to describe the level of work required of the person performing the position. Essential functions are outlined; however, other duties may be assigned, as needs arise, or as required to support the essential functions. Specific performance objectives may be developed each year to measure the performance of the tasks and functions listed in this job description.Remote work opportunities vary by location, department, and business need and are subject to change, as needed. Each manager will provide details on any telecommuting opportunities, as well as scheduling, within their departmentJob Requirements5 – 7 years of previous workers’ compensation claims handling experience preferredPossession of a current Texas Workers’ Compensation Adjuster License or an All-Lines Adjuster License ris equiredSpanish language skills (speak and understand) preferred, but not requiredKnowledge, Skills, and AbilitiesStrong judgment and decision-making skills, with the ability to effectively analyze claims exposure to determine the proper course of actionExtensive knowledge of Workers’ Compensation law, industry standards and medical and legal terminologyStrong working knowledge of the Texas Workers’ Compensation Act, including specific rules and case lawStrong working knowledge of various medical services normally provided to injured workersKnowledge of EDI (Reporting requirements for the State of Texas)Excellent organizational skills, demonstrating attention to detail, accuracy and ability to meet deadlinesAbility to work within a fast-paced, changing priority environmentSelf-motivated, with the initiative to prioritize and be self-directedRegular and punctual attendance is requiredAbility to communicate effectively, both verbally and in writing,Excellent interpersonal skills, with the ability to interact effectively with both colleagues and managers, across all levelsAbility to promote and maintain a team environment, willing to find accommodating solutions for our customers, companies, and the AgencyAbility to successfully adhere to company policies and procedures, as well as maintain strict confidentialityWork ConditionsAbility to perform approximately 90% sedentary work, exerting up to 10 pounds of force occasionally, and negligible force frequentlyAbility to lift up to 20 pounds, occasionallyRequires operation of a computer workstation, including keyboard and video displayAll requirements may be modified to reasonably accommodate physical or mental impairment