Lost Time Claims Adjuster - Workers' Compensation

Job Summary Salary range: $55,132.00 - $110,642.00 annually, plus bonus and benefits. Pay type is salary. The range reflects full compensation for this position. Pay will be determined based on location, education, experience, and related factors. The role is open to candidates residing in any of Encova’s payroll‑approved states: Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, Wisconsin. Job Objective The Lost Time Claims Specialist, Workers’ Compensation primarily manages indemnity claims. The specialist investigates, evaluates, and determines compensability for work‑related injury and disease claims following established guidelines to determine benefit eligibility. The specialist also serves as a resource to Medical Only Claims Specialists and Claims Specialist trainees, providing service in a cost‑effective manner and proactively collaborating across the enterprise to ensure alignment and continuous improvement. Essential Functions Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims to a cost‑effective conclusion. Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines. Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision. Takes recorded statements when necessary. Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed within the designated authority levels. Utilizes proactive reserving behaviors to ensure adequate case reserves that reflect the probable ultimate outcome based on the current known circumstances throughout the life of the claim. Actively identifies and develops the investigation of and pursuit of subrogation recoveries when possible. Consults with assigned claim director, return‑to‑work specialists, nurse case managers, internal/external medical and legal on current and/or recommended treatment, litigation or rehabilitation plans to ensure claims outcomes are achievable and appropriate. Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs and promote quality medical care. Works collaboratively with the injured worker, employer, assigned return‑to‑work specialist and medical providers to facilitate the injured worker’s safe and timely return to work. Manages claims litigation, including expenses, by collaborating and providing direction to panel counsel throughout the life of the claim. Analyzes reports from external resources such as physicians, attorneys, and/or vocational rehabilitation experts to evaluate and adjust claim strategies as needed. Evaluates and negotiates claim settlements utilizing human relation skills and technical knowledge to achieve the best possible outcome. P presents and summarizes claim details at internal team staffing, participates in discussions, and provides guidance as needed. Consults with assigned claim director if the loss becomes significantly complex or presents significantly increasing financial exposure. Follows established claims best practices related to medical management, litigation, fraud/abuse and recovery. Effectively and independently uses available resources to prioritize, organize, and complete work in a timely manner to meet jurisdictional requirements, timeframes, and internal metrics. Develops presentations for special projects such as internal/external meetings and conferences as needed. Along with the claim director, regional vice president and other claims staff, participates in claim reviews, onboardings, etc. for our policyholders and agents. Proactively collaborates with our policyholders to ensure alignment of objectives and foster continuous improvement. Other Functions Nonessential function: other duties as assigned. Qualifications Bachelor’s Degree from an accredited college or university is preferred. Three years of experience in workers’ compensation insurance required. Ability to manage claims through the litigation process. Internal candidates must demonstrate knowledge of Encova Best Practices guidelines and meet quality standards. One valid workers’ compensation adjuster license is strongly preferred. Must be eligible to obtain additional licenses as required. Must pass the claims adjuster license exam(s) within 90 days of being hired. Preference may be shown to candidates with multiple state claims‑management experience. Experience in workers’ compensation claims practices and laws, court procedures, precedents and state statutes. Ability to use logic and sound reasoning to identify alternative solutions for problem solving. Strong written and verbal communication skills. Strong analytical skills. Ability to multitask and manage time effectively and productively. Work effectively independently as well as in a team environment. Develop and maintain strong, effective internal and external relationships. Work effectively in a paperless environment. Skilled in the use of laptops, claims management systems, and other typical business‑related programs such as Microsoft Office suite. Will reside and work within one of Encova’s payroll‑approved states. Benefits Health, Dental & Vision Insurance Company‑provided life and income protection plans Eligibility to participate in a company incentive bonus program 401(k) Retirement Plan – 100% company match up to 7% on annual salary Paid Time Off, Paid Holidays, and Floating Holidays Flexible Work Arrangements – Hybrid and remote depending on the role Encova Insurance is an Equal Opportunity Employer and participates in E‑Verify. 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. #J-18808-Ljbffr