The primary purpose of this position, under the Claims Supervisor, is to administer claims and control medical costs and indemnity benefits for workers compensation injuries or illnesses. The Sr. Adjuster is responsible for high level investigations, handling all litigated claims, complex claims and subrogation recovery.
Evaluates work injury claims and medical reports to determine appropriateness of treatments and disability benefits in accordance with jurisdictional statutes and rules. Refers cases to medical management as appropriate. Proactively manage all claims in accordance with company standards. Ensure all medical and indemnity benefits are paid accurately and time.
Provides excellent customer service and benefit information to claimants. Communicates coverage and legal responsibilities to the injured employee, supervisor, attorneys, responsible parties, physicians and other medical providers.
Determines what appropriate legal notices and correspondence are to be issued and required by the Industrial Commission of Arizona. Determines if the claim is a reportable claim under the guidelines of the Occupational Safety and Health Act (OSHA) and assigns an OSHA status to the claim as required. Conduct dispute resolution with claimants and/or their attorneys. Inform appropriate departments regarding the claimants disability status.
Conducts direct investigations including but not limited to background checks, written and/or recorded statement of the claimant, witnesses, interview managers, discuss with safety experts, physicians, obtaining police records and other documents and court records as the case develops.
Directs and monitors outside investigations which may include; video surveillance and background checks, photography of accident scenes or equipment or accident re-constructionists and witness statements.
Coordinates with the internal Nurse Case Manager to authorize medical treatments, evaluates progress of claim and coordinates consultations and referrals. Composes correspondence and reports to attending or independent evaluating physicians summarizing treatment and prognosis requesting opinions of current findings. Actively utilizes cost containment measures and programs, appropriate subrogation and vendors.
Develop, maintain and adhere to action plans and reserves on high level and complex indemnity claim while pro-actively managing claims to resolution. Document communications and claim management activities.
Establish and maintain cost drivers and data elements to ensure accurate NCCI and Medicare reporting. Identify settlement opportunities. Negotiate settlements with claimants and their attorney. Ensure Defense follows all reporting requirements and properly defends Banner Healths interest at all hearing and trials.
Proficiency level typically attained through a combination of an Associates degree in a related field and seven to ten years of job related experience.
Must possess current knowledge of workers compensation rules, regulations, procedures and protocols. Prior litigation and complex medical claim handling required. Must excel in detailed investigations, complex claim reserving and proven strategic claim resolution outcomes. Requires the ability to use effective verbal and written communications, while dealing with a variety of difficult and complex human relation situations. Must be a team player. Must be able to organize and prioritize daily workloads to meet deadlines and work under pressure. Must have intermediate level of medical terminology and basic anatomy. License or certification may be required for some work assignments.
Requires the ability to work effectively with all common office software as well as excel pivot tables.
Prefer workers compensation license, or Associate in Risk Management certification or related in the field. Additional related education and/or experience preferred.
Additional related education and/or experience preferred.
Internal Number: 267372
About Banner Health
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.