Claims Adjuster/Examiner

Job Description

Job Description

Jones Jones LLC is a trusted leader in workers’ compensation defense, claims management, and regulatory compliance. With decades of industry experience, we proudly serve clients through our affiliated entities - NYTIC, Emerald, Mediation Resolution Management, and Medical Management Group - offering innovative solutions, collaborative teamwork, and unwavering professionalism. Our firm values growth, integrity, and excellence across every level of our organization.

We are seeking an experienced Claims Adjuster/Examiner who is interested in growing and expanding their expertise across multiple entities, including NYTIC, Emerald, Mediation Resolution Management and Medical Management Group. This unique cross-functional role offers exposure to complex claims, compliance, and ADR operation. This role is perfect for a skilled examiner seeking to broaden scope, strengthen leadership, and grow within a premier workers’ compensation firm.

This is a 100% fully remote position.

Essential Functions

1. Claims Adjusting Work (NYTIC / Emerald):

• Perform intake and coverage verification via WCB employer coverage search
• Initiate three-point contact (employer/clamant/provider) within 24 hours
• Conduct compensability analysis and develop action plans
• Ensure timely filings: employer first report, EDI FROI/SROI via Emerald, PH-16.2, and C-240 wage statement
• Calculate AWW and benefit rates; set and review reserves at key milestones
• Monitor treatment against NY Medical Treatment Guidelines; manage MG-2 variance requests and C-8.1 objections
• Route medical bills to bill review and ensure fee schedule compliance
• Prepare for hearings and maintain eCase updates
• Evaluate resolution paths (SLU, LWEC, Section 32); manage subrogation and third-party notices

2. Licensing & Compliance (Jones Jones):

• Collaborate with the Compliance team on licensing forms and regulatory filings
• Review TPA scorecards and ensure compliance with WCB standards
• Track and invoice licensing fees and renewals
• Support examiner training and respond to licensing-related inquiries

3. ADR (MRM):

• Manage intake, eligibility, and notices under the collectively bargained ADR program
• Coordinate and schedule mediations
• Draft case summaries and settlement proposals
• Ensure adherence to Medical Network protocols and document variances
• Prepare and route settlement paperwork, including Section 32 agreements
• Maintain dashboards of ADR cycle times and outcomes for annual reporting
• Obtain loss runs from wrap-up sponsors

4. MMG

• Evaluate Independent Medical Examination (IME) reports for accuracy and compliance

• Assist with administrative tasks such as schedule coordination and provider panel management

Competencies

• Excellent and professional verbal and written communication skills
• Strong understanding of workers’ compensation best practices
• Exceptional organizational skills and attention to detail
• Excellent time management skills with a proven ability to meet deadlines
• Strong analytical and problem-solving skills
• Ability to perform well in a fast-paced, dynamic environment
• Ability to maintain confidentiality and exercise discretion and sound judgment
• Proficient with Microsoft Office Suite or related software

Qualifications

• Bachelor’s degree in business administration or related field
• Active Independent Adjuster License (New York State required)
• 3 - 5 years of claims management experience
• Must have experience with filing FROIs and SROIs
• Must have EDI filing experience

Apply today to join a firm with over a century of success and a future focused on innovation. Jones Jones LLC is an equal employment opportunity employer.