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Career Story: Workers' Compensation Claims Adjuster

Workers' Compensation Claims Adjuster

Job Title: Workers Compensation Claims Examiner

Type of Company: I work for a third-party administrator that adjusts workers' compensation claims for employers and various insurance companies. We handle self-insured claims for employers that fund the payments of their own claims as well as handle claims for specific insurance companies that pay the claims.

Education: AS, Legal Technology, University of Maine •• AIC (Associate in Claims) Designation, AICPCU/IIA

Previous Experience: I started working as an insurance defense paralegal for several different law firms over 12 years. That led me to obtain my AIC designation to become a workers' compensation claims examiner. I have been working for a third-party administrator for the past year.

Job Tasks: I handle workers' compensation claims from start to finish. When someone is injured at work, the claim is reported to us. I first make contact with the employer, the employee and the medical provider treating the employee for their injury. I obtain a detailed account of how the injury occurred from all parties. I often have to take a recorded statement to document the employee's version of the incident and this can later be used to confirm facts or even at times to contest a settlement, if the claim is denied and eventually litigated.

After gathering all of the facts of the claim, I make a determination of whether the employee's claim is work-related and whether lost time benefits are due to the employee, and I also authorize appropriate medical treatment. We handle workers' compensation claims in many states, so each claim has to be handled according to the locality's statutes. Once I determine that the claim is or is not compensable, I have to put money on the file (a/k/a reserves). I have to estimate how much money it will cost to pay all of the medical bills, lost time benefits and expenses from start to finish. I also must file forms in each state that tell the state whether the claim has been accepted or denied. Each state has different forms and different requirements. After the initial investigation, I monitor the file, pay medical bills, lost time benefits, and expenses when they come in. I set appropriate diaries on each claim to review periodically. We try and close claims as quickly as possible. I also negotiate settlements in some claims and I direct and manage any attorneys assigned to the claims if the claim is contested.

Best and Worst Parts of the Job: The best part of my job is the fact that I am responsible for myself and for my files. It doesn't matter what anyone else is doing on their files as we are each held accountable for our own actions and if something doesn't get done or is done wrong, no one can try and pass the blame. I enjoy that the most about the job.

The worst part of the job is that it feels at times like you are punished for doing a good job. The more hours I work each week, the more work they give me. If my diaries and mail are up to date, management gives me even more files. Right now I have a case load of 200 open claims when others in the office have less than 125 files and that case load is becoming difficult to manage.

Job Tips: I would recommend that anyone pursuing this career realize that you must have the ability to multi-task. You will not succeed if you are unable juggle several things at once. But in order to do that, you have to also be able to set priorities and to shift priorities as occasion arises. I would also recommend obtaining your AIC designation. It gives you very good knowledge of many forms of insurance and is helpful when you take licensing exams.

Additional Thoughts: I think that to excel in this field, you must be able to be analytical and independent. You should be a person who looks to find answers independently, without running to another co-worker or supervisor for answers. You have to be able to deal with people who may be angry over a decision that you made on the claim in a calm and professional manner and be able to reasonably and intelligently explain the basis for your decisions. If you are quick to become angry or lose your composure easily, this is not the career for you.

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