Workers Comp Lead (Claims Adjuster Specialist) Qual-Lynx, Egg Harbor Twp, NJ

The Claims Adjuster Specialist will work independently Investigate, evaluate, and resolve assigned claims of a more complex or litigated nature in a timely manner in accordance with legal statutes, policy provisions and company guidelines and serves as a Lead for the team\.
? Manage diary in accordance with Best Practices and complete tasks to ensure that cases move to the best financial outcome and timely resolution\.
? Makes recommendations for new claims assignments and file directions\.
? New hire training
? Assists with PARs \(Payment Authorization Requests \)Reviews
? Participate with management with team talent reviews
? Performs summary reviews of the teams? claims and provider direction and feedback
? Evaluate claimant eligibility; communicate with attending physician, employer and injured workers\.
? Work with both the claimant and their physician to medically manage the claim, from initial medical treatment to reviewing and evaluating ongoing treatment and related information\.
? Work directly with employers to facilitate a return to work, either on a full\-time or modified duty basis\.
? Confirm coverage and applicable insurance policy or coverage document and statutory requirements\.
? Identify potential for third party recovery, including subrogation, Second Injury Fund or other fund involvement \(when applicable\) and excess or reinsurance reimbursement\. Pursue the process of reimbursement and complete posting of recovery to the claim file, where appropriate\.
? Identify potential for disability or pension credits or offsets and apply same where appropriate\.
? Ensure timely denial or payment of benefits in accordance with jurisdictional requirements\.
? Establish claim reserve levels by estimating the potential exposure of each assigned claim, establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure\.
? Establish compensability status through case investigation and evaluation and application of jurisdictional statutes and laws\.
? Where litigation is filed, evaluate exposure and work with defense counsel to establish strong defenses, litigation plan of action, set legal reserve and manage litigation over life of claim\.
? Close all files as appropriate in a timely and complete manner\.
? Maintain closing ratio as directed by management team\.
? Oversee and coordinate medical treatment for injured employees and provide information to treating physicians regarding employees? medical history, health issues, and job requirements; provide direction to assigned nurse case manager where applicable\.
? Complete PARs \(payment authorization request\) when applicable\.
? Comply with all excess and reinsurance reporting requirements\. Manage self\-insured retention reporting\.
? Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account\-related issues\.
? Provide a high degree of customer service to clients, including face to face interactions during claim reviews, meetings and similar account\-specific sessions\.
Requirements include:
Bachelor?s Degree strongly preferred, HS Diploma required
A minimum of 5 years of experience in an insurance medical/health or legal related industry, handling workers? compensation claims required\.
Expertise in Workers Compensation claims handling practices and legislature\.
Deep knowledge of client and carrier claims procedures
Significant understanding of self\-insured retention, excess and reinsurance reporting
Workers Compensation Licensure \(i\.e\. AIC, WCCC\) a plus
Strong leadership skills
Proficiency in MS Office \(Work and Excel\)
Fluent in medical terminology and medical/injury treatments\.
Experience with claims related software strongly preferred
Excellent communication and negotiation skills
Proven customer service/client relations skills with the ability to communicate with all levels of an organization
Strong organizational skills with the ability to multi\-task and meet deadlines in fast paced environment
Primary Location: Egg Harbor Twp\-New Jersey
Work Locations: 100 Decadon Drive Egg Harbor Twp 08234
Job: Bus Ops\-\-Claims
Schedule: Regular
Shift: Standard
Employee Status: Individual Contributor
Job Type: Full\-time
Job Level: Day Job
Travel: Yes, 25 % of the Time
Job Posting: Jul 30, 2018, 4:22:01 PM
Qualified applicants will be considered for employment without regard to age, race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status\. Need an accommodation? Email: SeeYourself@cigna\.com

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