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Workers Compensation Claims Adjuster Job Duties

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Workers Compensation Claims Adjuster Has 13+ Job Duties

The Workers Compensation Claims Adjuster – this is an excerpt from a manual I wrote 10 years ago. The only area I would add is the MSA component.

One of the most thankless jobs in insurance is the claims adjuster position. This manual may point out how file reserves and closings are handled by an adjuster.
It is not the adjuster, but the WC insurance system as a whole that causes overcharges in employers’ premiums. The claims adjuster is the “mediator” between the claimants and the respective insurance companies.
Picture Of Doctor In Front Workers Compensation Claims Adjuster And Medical Personnel At Back
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The claimants want to be reimbursed or provided with whatever they ask, and the insurance company wants the claim to be settled for the least amount of funds possible, without the costs of litigation. Most claims adjusters are overloaded with claims. A claims adjuster must be the master of time management or they will quickly drown in their claims load.

Anything that will help a claims adjuster do their job can only help keep your reserves as low as possible. The Four Secrets of Saving WC $ on page 19 will help reduce the amount of time spent by the adjuster on your WC files. An adjuster only has so much time to devote to each file, so any extra time that you can give the claims adjuster will enable the adjuster to spend time on your files trying to reduce your costs, not just working on the files.

There are numerous tasks in a Workers’ Compensation claims adjuster’s job:

1. Investigate claims within 24 – 48 hours after receipt of the First Report of Injury.

2. Provide benefits to injured employees.

3. File proper forms with State WC Board.

Women Workers Compensation Claims Adjuster under maintenance
Wikimedia Commons – Suzanne M. Day

4. Set initial reserves on new claims and review reserves on established claims (usually for increases).

5. Pay bills on claims (medical, rehabilitation, defense attorney).

6. Settling claims.

7. General clerical functions.

8. Completion of periodic claims status reporting to insureds, carriers, and/or reinsurers

9. Maintaining up-to-date file documentation of any development on the claim including phone calls, correspondence received and sent, review of medical notes, etc.

10. Minimum of monthly reviews of the claims (via diaries) to assure the claim is proceeding accordingly toward closure. Maintain and update periodic action plans to move the claims toward closure.

11. Authorize and schedule medical appointments for the injured employees and follow up for receipt of medical documentation including work status reports.

Picture Business people Workers Compensation Claims Adjuster Group
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12. Follow up with employers to determine if work is available for the injured employee (limited duty or full duty) and/or assign vocational rehabilitation to assist the claimant in finding alternative work to lessen exposure.

13. Review files for reserve reductions or closings.

Please note that reviewing reserves for reductions and file closings is the lowest-rated priority on the task list for claims adjusters. Why are they the lowest priority in the adjuster’s daily tasks? It is the nature of the insurance system.

Your efforts should be focused on the parts of your WC claims that will reduce the amount of time the adjuster spends on tasks #1 – #12 and increase the amount of time the adjuster spends on #13.

That is why it is so important that you review your monthly or quarterly loss runs upon receipt. If you see files that should be closed or reserves that are too excessive, email your workers compensation claims adjuster.

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James Moore

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Mgmt Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications

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