Synectics Inc
Claims Adjuster - Workers Compensation
Synectics Inc, Jersey City, New Jersey, United States, 07390
Claims Adjuster - Workers Compensation Synectics Inc•Jersey City, NJ, US
Job Description
To analyze mid- and high-level workers compensation claims to determine benefits due; ensure ongoing adjudication within company standards and industry best practices; identify subrogation of claims and negotiate settlements.
Manage workers compensation claims determining compensability and benefits due on long-term indemnity claims, monitor reserve accuracy, and file necessary documentation with state agency.
Develop and manage workers compensation claims’ action plans to resolution, coordinate return-to-work efforts, and approve claim payments.
Approve and process assigned claims, determine benefits due, and manage action plan pursuant to the claim or client contract.
Manage subrogation of claims and negotiate settlements.
Communicate claim action with claimant and client.
Ensure claim files are properly documented and claims coding is correct.
May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
Maintain professional client relationships.
Perform other duties as assigned.
Support the organization’s quality program(s).
Lost Time Claim Management.
End-to-end handling of indemnity claims, including initial investigation, compensability determination, and ongoing management.
Reserve claims for ultimate exposure.
Handle caseload of diaries, correspondence (including email and faxed documentation).
Jurisdictional Knowledge: In-depth understanding of PA and NJ workers’ compensation statutes, regulations, and case law; familiarity with state-specific forms (e.g., LIBC forms for PA, WC forms for NJ); EDI filing and clearing of errors.
Wage Loss & Benefit Calculation: Accurate calculation of Average Weekly Wage (AWW) and Temporary Total Disability (TTD) benefits; application of PA’s 7-day waiting period and NJ’s 7-day retroactive rules.
Medical Management: Coordinate treatment plans, utilization review, and compliance with state medical fee schedules; familiarity with NJ’s authorized provider rules and PA’s panel provider requirements.
Litigation Handling: Manage claims in litigation, including working with defense counsel, attending hearings, and preparing testimony; understanding of PA’s Supersedeas process and NJ’s informal/formal hearing procedures.
Return-to-Work Coordination: Develop modified duty programs and collaborate with employers to facilitate early return-to-work.
Communication & Documentation: Regular interaction with injured workers, employers, medical providers, and attorneys; clear and timely documentation of all claim activities.
Superior customer service and phone etiquette.
Negotiation & Settlement: Experience negotiating lump-sum settlements and Section 32 agreements (NJ) or Compromise & Release (PA); drafting settlement evaluations and experience working with Medicare requirements.
Qualifications
MUST HAVE 5 years’ experience directly managing lost time claims in both NJ and PA; experience in other states is beneficial.
License preferred but not required.
Benefits Healthcare Insurance:
Synectics offers eligible employees and their dependents healthcare coverage through BlueCross BlueShield of Illinois. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full‑time employment with Synectics. Premiums are subsidized by Synectics.
Dental Insurance:
Synectics offers eligible employees and their dependents a dental plan through MetLife. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full‑time employment with Synectics.
Vision Insurance:
Synectics offers eligible employees vision insurance through VSP. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full‑time employment with Synectics.
401(k) Plan:
The Synectics Inc. Investment Savings Retirement Plan. Entitled employees 21 years of age or older can invest on first enrollment date at least 30 days after employment begins. Enrollment dates are each January 1st, April 1st, July 1st, and October 1st.
Technical Certification Bonus:
A bonus up to $500 for an approved professional certification relating to your current position, awarded 90 days after successful completion documentation. Only one per calendar year per employee; only active employees eligible.
Synectics is an equal opportunity employer.
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Job Description
To analyze mid- and high-level workers compensation claims to determine benefits due; ensure ongoing adjudication within company standards and industry best practices; identify subrogation of claims and negotiate settlements.
Manage workers compensation claims determining compensability and benefits due on long-term indemnity claims, monitor reserve accuracy, and file necessary documentation with state agency.
Develop and manage workers compensation claims’ action plans to resolution, coordinate return-to-work efforts, and approve claim payments.
Approve and process assigned claims, determine benefits due, and manage action plan pursuant to the claim or client contract.
Manage subrogation of claims and negotiate settlements.
Communicate claim action with claimant and client.
Ensure claim files are properly documented and claims coding is correct.
May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
Maintain professional client relationships.
Perform other duties as assigned.
Support the organization’s quality program(s).
Lost Time Claim Management.
End-to-end handling of indemnity claims, including initial investigation, compensability determination, and ongoing management.
Reserve claims for ultimate exposure.
Handle caseload of diaries, correspondence (including email and faxed documentation).
Jurisdictional Knowledge: In-depth understanding of PA and NJ workers’ compensation statutes, regulations, and case law; familiarity with state-specific forms (e.g., LIBC forms for PA, WC forms for NJ); EDI filing and clearing of errors.
Wage Loss & Benefit Calculation: Accurate calculation of Average Weekly Wage (AWW) and Temporary Total Disability (TTD) benefits; application of PA’s 7-day waiting period and NJ’s 7-day retroactive rules.
Medical Management: Coordinate treatment plans, utilization review, and compliance with state medical fee schedules; familiarity with NJ’s authorized provider rules and PA’s panel provider requirements.
Litigation Handling: Manage claims in litigation, including working with defense counsel, attending hearings, and preparing testimony; understanding of PA’s Supersedeas process and NJ’s informal/formal hearing procedures.
Return-to-Work Coordination: Develop modified duty programs and collaborate with employers to facilitate early return-to-work.
Communication & Documentation: Regular interaction with injured workers, employers, medical providers, and attorneys; clear and timely documentation of all claim activities.
Superior customer service and phone etiquette.
Negotiation & Settlement: Experience negotiating lump-sum settlements and Section 32 agreements (NJ) or Compromise & Release (PA); drafting settlement evaluations and experience working with Medicare requirements.
Qualifications
MUST HAVE 5 years’ experience directly managing lost time claims in both NJ and PA; experience in other states is beneficial.
License preferred but not required.
Benefits Healthcare Insurance:
Synectics offers eligible employees and their dependents healthcare coverage through BlueCross BlueShield of Illinois. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full‑time employment with Synectics. Premiums are subsidized by Synectics.
Dental Insurance:
Synectics offers eligible employees and their dependents a dental plan through MetLife. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full‑time employment with Synectics.
Vision Insurance:
Synectics offers eligible employees vision insurance through VSP. Eligibility begins on the 1st day of the calendar month following 60 days of continuous full‑time employment with Synectics.
401(k) Plan:
The Synectics Inc. Investment Savings Retirement Plan. Entitled employees 21 years of age or older can invest on first enrollment date at least 30 days after employment begins. Enrollment dates are each January 1st, April 1st, July 1st, and October 1st.
Technical Certification Bonus:
A bonus up to $500 for an approved professional certification relating to your current position, awarded 90 days after successful completion documentation. Only one per calendar year per employee; only active employees eligible.
Synectics is an equal opportunity employer.
#J-18808-Ljbffr