TPA Claims Specialist III-Lost Time Adjuster
General Description: Senior Level lost time claim adjuster for workers compensation
- Advanced Knowledge of claims function and processes.
- Ability to effectively communicate with internal and external customers.
- Expert understanding of workers compensation or disability claims management, strategies, resolution techniques and adjusting.
- Technical/administrative capability to adjust lost time, utilizing the features of the TPA claim management systems.
- Participates in claim advocacy and negotiations, including claim denials, reserving files, and claim reporting, issuing payments, attending hearings, conciliations or mediations and filing of state forms.
- Determine compensability of the claim as it relates to the worker compensation jurisdiction.
- Review and approval of loss time, medical services and expenses to be paid of the claims file.
- Plan and attend claim reviews with clients, carriers and auditors.
- Negotiate and recommend claim file settlements to the client.
- Ability to identify client issues, build a plan towards resolution, execute and manage internal and external expectations effectively.
- Analyzes claims based on the TPA best practices as outlined in the "Policy and Procedures" manual.
- Skill set to implement new business with "Special Account Instructions".
- Understand the financial impact of losses.
- Ability to communicate with internal resources to explain results and help develop improvement for risk management plans.
- Ability to develop high quality output documents for internal resources, clients and carriers
- Understand client business issues.
- Attend sales presentations.
- Act as a team leader with the non lost time claim adjuster and the medical case manager.
Knowledge, Skills and Abilities:
- Ideal candidate will have a minimum of 10 - 15 years of claims administration experience.
- College degree preferred but high school diploma or graduate equivalent degree required.
- Expert in MS Office suite of products, especially MS Excel.
- Superior written and oral communication skills.
- Ability to lead a team and work well in a team environment.
- Must have expert analytical thinking and problem-solving skills.
- Superior organizational skills required.
- Expert negotiation skills required.
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