Workers Compensation Claims Adjuster Resume Samples

Description :

1. Investigated on the job accidents by interviewing the claimant, store personnel, looking at the video when available.
2. Influenced and coordinated with the stores and the claimant for return to work of the employee even if in a modified duty capacity.
3. Determined the most cost-effective resolution of each claim as responsible for all payments for medical, compensation, legal.
4. Solved and effective communication in order to negotiate and reach a settlement on claims that require that type of resolution.
5. Prepared detailed monthly claims report to be discussed in monthly claims meetings.
6. Monitored claim for reserve accuracy and file the necessary legal documentation with each State agency in order to be compliant.
7. Responsible for coordinated all care for the claimant by approving and authorizing treatment, surgery, medications, and appointments.

Experience

2-5 Years

Level

Junior

Education

Diploma

Description :

1. Analyzed and processing workers' compensation claims by investigating and gathering information to determine the exposure of the claim.
2. Assigned timely reserves for the life of the claim. Calculated and pay benefits due; approved all claim payments.
3. Handled litigated claims; communicated with the appropriate parties involved and insured timely and cost-effective claims resolution.
4. Handled worker's compensation caseloads from inception to final settlement including communicating with policyholders.
5. Analyzed, and evaluated claims in a timely manner Ensure legal compliance by following guidelines and account contracts.
6. Resolved claims within evaluation Calculate and assign appropriate expenses to claims while monitoring adequacy.
7. Trained and acted as the main point of contact for site employees who need help or have questions on new software.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Answered heavy phone lines, set up claims for work accidents.
2. Verified incident details and injured body parts, set up medical treatment, billing information.
3. Created computer files, monitor treatment until final release. Heavy Client Contact.Set up TTD payment if needed.
4. Handled all aspects of claims from origination to resolution including investigating and evaluating client claims for benefits.
5. Communicated with defense attorneys to settle litigated claims.
6. Consulted with store managers, supervisors, and attorneys in the evaluation of claims Analyze case facts and monitor activities.
7. Reviewed written, audio, photographic, and video evidence on claims Handled legal issues with or without the use of a defense attorney as necessary.

Experience

2-5 Years

Level

Junior

Education

Insurance

Description :

1. Managed Litigated and Non-Litigated Claims Acted as a Liaison among injured workers, employers, and attorneys.
   
2. Prepared file documentations and reports Oversaw prompt delivery of benefits; Calculated, reviewed and approved wage payments.
3. Reviewed Vocational Rehabilitation Plans; Found moderate or alternate job duties for injured workers Reviewed files from inception to closure.
4. Processed worker's compensation claims in conjunction with the insurance company that was paying for the claim.
5. Physical therapy clinics to advise that patients had been approved for physical therapy.
6. Authorized medical treatment and referrals.
7. Communicated between claimants, employers and medical providers.
8. Filed claims, select documents, stamp files/papers Accomplishments Working with the department of human resources.

Experience

10+ Years

Level

Senior

Education

Indiana Only

Description :

1. Successfully handled a high volume of Workers' Compensation claims in a fast pace environment.
2. Completed initial investigations and contacts with clients in a timely fashion, to obtain accurate claim details, and make compensability decisions.
3. Set monetary reserves, for all possible payments and exposure on each claim.
4. Maintained positive rapport with internal and external customers, to promote loyalty and establish credibility.
5. Managed and met claim deadlines to obtain a high claim closure rate.
6. Set challenged work goals for success in a self-driven, independent environment.
7. Provided superior customer service to all clients and contacts to ensure confidence and satisfaction in the services of our company.
8. Negotiated lien payments and treatment options with medical providers and lien claimants.

Experience

2-5 Years

Level

Junior

Education

B.S

Description :

1. Assisted during open enrollment periods ensuring the employees and their dependents were enrolled as requested.
2. Managed one client's medical and child care flexible spending account from enrolling the participants.
3. Justified payroll contributions through reviewing and processing bills for payment.
4. Processed voids and refund checks applying them to the proper claim and preparing the checks for deposit to the respective client's account.
5. Processed dental and medical bills for payment.
6. Set up workers' compensation claims, filed appropriate state forms, reviewed bills for compensability.
   
7. Prepared reports for clients and re-insurance carriers.

Experience

10+ Years

Level

Senior

Education

Diploma

Description :

1. Reviewed and processed a caseload of workers' compensation claims.
2. Direct cared for injured workers with the help of Nurse Case Managers.
3. Arranged transportation to medical appointments if the unreliable vehicle or unable to drive due to injury.
4. Paid mileage for use of personal vehicles if driving over 15 miles to appointments.
5. Investigated by recorded interview of the employee, employer and witnesses to determine if the claim is compensable.
6. Verified coverage per individual policy and maintain adequate money reserves to pay disability wages while off work.
7. Requested surveillance on injured workers if fraud was suspected.
8. Turned claims over the State Insurance Fraud Unit.

Experience

10+ Years

Level

Senior

Education

Technology

Description :

1. Ensured that medical bills were paid and that the injured workers returned back to work in a timely manner.
2. Contacted with the employer, employee and medical facilities throughout the life of the claim serving as a bridge of communication between all parties.
3. Responsible for knowing the claim laws for each of those states.
   
4. Trained in all different claims systems that the company used for workers comp.
5. Worked with MS Word / Works, Excel and Outlook.
6. Licensed has expired but willing to get it renewed at any time.
7. Evaluated and investigated claims for potential fraud.

Experience

2-5 Years

Level

Junior

Education

General

Description :

1. Investigated and analyzed claims to determine liability and compensability of claims for various state jurisdictions.
2. Prepared litigated files for hearings and negotiating settlements with the claimant's counsel in permanency cases.
3. Determined the need to create and assemble case files.
4. Contacted injured workers to ensure the injured worker was receiving proper care.
5. Prepared correspondence and responded to inquiries on employees for the company in relation to injury.
6. Processed bi-weekly indemnity payments for lost-time claims.
7. Reviewed and processed medical bills for payment.

Experience

5-7 Years

Level

Executive

Education

Criminal Justice

Description :

1. Managed over large deductible and self-insured claims files.
2. Oversaw claims for the region and National Accounts.
3. Investigated claims to determine the extent of coverage responsibilities.
4. Conducted interviews, corresponded with claimants and witnesses.
5. Attended mediations, responded timely to all Petitions for Benefits filed.
6. Authorized all medical care and directed attorneys in all phases of litigation.
7. Covered for two medical-only adjusters who are on simultaneous disability.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Evaluated claim potential/expenses and set proper reserves.
2. Documented files with necessary reports and notes.
3. Monitored disability status with regards to return to work date/level of abilities and any potential long term/permanent disability.
4. Managed medical and bills in a timely manner.
5. Required knowledge of medical terminology and labor laws.
6. Responsible for investigating and managing newly reported and existing portfolios of open workers.
7. Provided quality secretarial service while working with clients and investigators.

Experience

7-10 Years

Level

Management

Education

Medical Terminology