Claims Adjuster Professional Trainee

Job Title: Claims Adjuster Professional Trainee

Department: Claims

Reports to: Claims Manager

Position Summary:

This position will be responsible, following the initial training phase, for the adjudication of all assigned claims in accordance with the Act, governing rules and regulations, related case law and company procedures. Case complexity assignment is determined by the responsible claims manager and is guided by the level of training and performance of the claims adjuster trainee candidate.

The Claims Professional Trainee position is designed to introduce the individual to the workers' compensation claims function of New Mexico Mutual over a one-year (1) period of time. This candidate will have access to a comprehensive and formal training program under the direct guidance and supervision of our claims training manager, with active participation from other claims management personnel and claims specialists.

Essential Functions:

• This claim training will cover claim investigation, compensability, policy coverage, statutory law, case law, benefits analysis and payment, litigation, medical and claims resolution.
• Responsibilities include effective and consistent partnership with the employer, injured worker and medical provider, administration of benefits, litigation management and claims resolution.
• Verify claim information including but not limited to: documentation of the claim history; taking recorded statements from workers and witnesses, coordination of medical care.
• Document all activities in the claim management system. Responsible for outside legal counsel assignments, RTW strategies & all other expert assignments.
• Upon determination of compensability: Set and monitor reserves according to company policies and the worker’s injury, issue benefit checks in accordance to statutory requirements, and demonstrate proficiency in the application of state statutes, related case law and to interpret and comply with company claims standards, policies and procedures.
• Make required filings and ensure benefit payments within the established time frames and guidelines. Prepare, attend, and present a majority of all mediations and hearings. Represent the company at trial.
• Maintain a diary on all open claims. Document all relevant information to provide a clear history of events and a proper audit trail. Set review dates based on claim complexity or standard review criteria.
• Perform other duties as assigned.