At EMC, you'll put your skills to good use as an important member of our team. You can count on gaining valuable experience while contributing to the company's success. EMC strives to hire and retain the best people by engaging, developing and rewarding employees.
**This position is eligible to work from home anywhere in the United States**
Exercises independent judgment in the investigation, evaluation, negotiation, and disposition of moderately complex workers’ compensation claims, within limitations of authority outlined in the Claims Guide. Communicates with insureds, agents, and experts regarding coverage and claim status or questions.
Essential Functions
Reviews and evaluates the claim notice, lawsuits, contracts, state statutes, and policies to verify the appropriate coverage, deductibles
Initiates timely contact with insureds and injured worker to explain the claims process, and begin investigation to determine compensability, and appropriate jurisdiction for the correct state statues.
Obtains statements as appropriate from insured, injured worker, witnesses, and all other pertinent parties
Secures appropriate video, pertinent evidence, and recommends hiring a field investigation or expert when appropriate
Documents claim activities, reserve analysis, summaries of reports in the claim system including Medicare (MSP) modules in the claims system.
Research medical treatment and diagnosis to gain understanding of claimant’s injury and medical history
Sets and monitors timely, adequate reserves in compliance with the company reserving philosophy and methodology throughout the life of the claim
Secures and reviews all necessary official reports, claim forms and documents, providing summaries of them to the claim file
Reviews bills, invoices, and receipts, including legal and litigation related expenses, for accuracy and appropriateness
Notifies all parties involved that legally require appropriate notice including but not limited to the state and other carriers as necessary.
Resolves questions of coverage, liability, and the value of the claims and communicates with insureds and claimants to resolve claims
Drafts and sends investigation letters and denial letters upon Supervisor approval
Provides prompt, detailed responses to agents, insureds, and claimants on the status of claims
Communicates with insured, claimants, and attorneys to negotiate the settlement of claims
Prepares settlement evaluations, negotiation ranges and target settlement numbers prior to negotiation
Determines and negotiates settlement amounts for resolution within assigned authority limits. Makes recommendations to management for settlement amounts outside of authority limits
Assists claims team members in handling of claims
Maintains continuing education credits and licenses current as required by jurisdiction
Submits referrals to the Special Investigation, Subrogation, external Medical Management, and internal Medical Review Units as Appropriate
Markets On Call Nurse (OCN), Return to Work (RTW), and Select Preferred Provider (SPP) programs to insured’s and identifies non-use for corrective measures
Prepares risk alerts for Underwriting and Risk Improvement
Education & Experience:
Bachelor’s degree or equivalent relevant experience
Three years of workers compensation claims adjusting experience or related experience
Attainment of all applicable state licenses within six months of hire
Relevant insurance designations preferred
Knowledge, Skills, and Abilities:
Strong knowledge of the theory and practice of the claim function
Good knowledge of insurance contracts, medical terminology and substantive and procedural laws
Ability to adhere to high standards of professional conduct and code of ethics
Strong knowledge of computers and claims systems
Strong written and verbal communication skills
Excellent customer service skills
Solid investigative and problem-solving abilities
Strong organizational abilities and empathetic interpersonal skills
Travel required; a valid driver’s license with an acceptable motor vehicle report per company standards required if driving
Per the Colorado Equal Pay for Equal Work Act, the hiring range for this position for Colorado-based team members is $69,643.41 - $89,430.74. The hiring range for other locations may vary.
Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.
All of our locations are tobacco free including in company vehicles.
