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Claims Adjuster - Hybrid role

Company: Encova Insurance
Location: Charleston
Posted on: November 23, 2022

Job Description:

We have two openings for this role. The positions will work predominately in the Charleston, WV office and upon training being completed will work on average three days per week from home. The role will report to a Director, Workers' Compensation Claims on the West Virginia Large Accounts team. Workers' Compensation claims handling experience in WV is strongly preferred. Experience in any of the following jurisdictions is a plus; VA, MD, PA or KY.We will consider hiring a senior level adjuster based upon experience and qualifications. JOB OBJECTIVE:
The Claims Adjuster manages both medical only and lost-time claims, including those with the potential to become serious and produce excessive costs. The Claims Adjuster is responsible for the investigation, evaluation and determination of liability for work-related injury and disease claims following established guidelines to determine benefit eligibility. The Claims Adjuster assesses expected losses and creates plans to minimize and/or eliminate risk factors in order to achieve effective claims outcomes. The position's objective is to provide superior service in a cost-effective manner by executing best claim practices to eliminate unwarranted losses.ESSENTIAL FUNCTIONS:
1. Methodically evaluates and establishes an action plan to manage medical and indemnity benefits associated with medical only and routine lost-time injury and occupational disease claims to their most cost-effective conclusion.
2. Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.
3. Decides the outcome of claims using sound judgment and applying established policy, procedures, regulations and guidelines.
4. Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels.
5. Actively investigates and pursues subrogation recoveries when possible.
6. Establishes and maintains reserve values, within authority limits, which accurately predict the losses reflecting the current known circumstances of the claim.
7. Consults with more experienced adjuster, supervisor or technical support staff as needed.
8. Investigates, evaluates, and negotiates settlements by applying technical knowledge and human relation skills to effect fair and prompt claim closure and to contribute to a reduced loss ratio.
9. Redirects the file to the appropriate subject matter expert if the claim becomes more complex or presents increasing financial exposure.
10. Applies effective protocols for medical management, litigation, fraud/abuse and recovery.
11. Presents claims and participates in discussion at team staffing.
12. Works collaboratively with injured employee, employer, outside counsel, health and rehabilitation professionals to manage the claims costs, promote quality medical care and timely return to work to achieve optimal cost-effective medical and vocational outcomes.
13. Along with the supervisor, Business Director and/or more experienced adjusters, assists in facilitating meetings with policyholders.
OTHER FUNCTIONS:
1. Nonessential function: other duties as assigned.
KNOWLEDGE, SKILLS AND ABILITIES:
* Bachelor's Degree from an accredited college or university is preferred.
* Must have one year experience in the field of insurance, claims investigation, legal, rehabilitation, or medical claims processing. Workers' compensation claims experience preferred.
* Must hold or be eligible to obtain a valid Adjuster's License in applicable states*.
* Must pass the claims adjuster license exam(s) for applicable states within 6 months of being hired.
* Familiar with best claims practices and applicable laws, court procedures, precedents and government regulations.
* Ability to use relevant information and individual judgment to determine whether events or processes comply with laws, regulations or standards.
* Basic ability to recognize and analyze new or changing information that could affect the claims handling strategy and/or potential claims cost, and effectively use the information to manage the claim.
* Ability to work effectively in a team environment.
* Ability to use logic and sound reasoning to identify alternative solutions for problem-solving.
* Basic understanding of how to apply general rules to specific problems to produce workable solutions.
* Ability to create and execute specific goals and plans to prioritize, organize, and accomplish work.
* Basic understanding of how to evaluate the relative costs and benefits of potential actions to choose the most appropriate one.
* Skilled in the use of office computers and other typical business-related programs.
* Ability to develop and maintain constructive and cooperative internal and external relationships.
* Ability to work effectively in a paperless environment.
This position has been evaluated in accordance with the Americans with Disabilities Act. Encova Insurance makes every effort to reasonably accommodate disabilities to permit performance of the essential functions and candidates who need such accommodation are encouraged to seek it. This description reflects the nature and level of work performed by associates in this position. It is not an all-inclusive inventory of duties, responsibilities and qualifications required. It provides an accurate overview of the work and skills needed to perform this position. Because job content may change from time to time, Encova Insurance reserves the right to add and/or delete functions from this job as it deems necessary for business reasons.Ready to join our team?
At Encova Insurance, we firmly believe that our associates drive our company's success by delivering unrivaled service to our customers. With success in mind, we make an ongoing effort to provide an environment that offers challenging, stimulating and financially rewarding opportunities.

Join us to discover a work experience where your diverse ideas will be met with enthusiasm - where you can learn and grow to your fullest potential.What you can expect from us
Join our family of industry leaders, and let us reward you with a competitive salary, bonus and benefits package that includes but is not limited to: a 401(k), wellness programs, bonus incentive plans and flexible schedules, with an early close of the office every Friday. Additionally, Encova aspires to be an outstanding corporate citizen in all the markets we serve; we encourage and support associate participation in community initiatives through our foundations.

Encova Insurance is an EOE/E-Verify employer.

Keywords: Encova Insurance, Charleston , Claims Adjuster - Hybrid role, Other , Charleston, West Virginia

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