Medical Only Adjuster - TPA

Job description

WHAT WE'RE LOOKING FOR The Medical Only Adjuster is responsible for confirming the compensability of workers’ compensation medical-only claims and closely monitoring assigned files for potential lost time exposure. The individual in this role maintains regular communication with insureds, claimants, employers, and medical providers and provides operational support to the broader claims team to ensure timely, accurate, and compliant claim handling. A GLIMPSE INTO YOUR DAY Confirms compensability of medical-only workers’ compensation claims in accordance with jurisdictional requirements and company guidelines. Maintains regular contact with clients, claimants, employers, and medical providers to obtain work status and monitor claim progression. Monitors medical-only claims for indicators of potential lost time and escalates files to a Claims Adjuster as appropriate. Assesses claims for potential subrogation opportunities and places appropriate parties on notice when identified. Authorizes medical treatment and confirms medical necessity and major contributing cause as warranted. Reviews, approves, and processes medical bills in a timely and accurate manner. Ensures all medical and hospital bills contain required information and documentation. Returns incomplete or incorrect bills to providers promptly for correction. Enters bills for payment and ensures timely processing in accordance with service standards. Maintains appropriate reserves on medical-only claims and updates reserves as needed. Schedules and coordinates medical appointments and diagnostic testing for injured employees. Follows up with medical providers regarding treatment status and maximum medical improvement (MMI). Maintains open and closed claim files and reviews files monthly to ensure timely progression and closure. Utilizes claim diaries to ensure timely completion of routine claim activities and appropriate file documentation. Assists Claims Adjusters with indemnity-related tasks as needed. Maintains accurate, organized, and up-to-date claim documentation. Effectively utilizes available technology and tools, including emerging and AI‑enabled solutions, to support efficient workflows, accuracy, and a positive client service experience. Special projects and other duties as assigned. WHAT SUCCESS LOOKS LIKE IN THIS ROLE High school diploma or equivalent. 1 year of experience in claims processing. Strong verbal and written communication skills with the ability to interact professionally with internal and external stakeholders. Ability to follow written and verbal instructions and adhere to established policies and procedures. Proficiency in Microsoft Office, including Word and Excel; ability to learn new systems and software applications. Demonstrated ability to manage multiple tasks, prioritize deadlines, and work effectively in a fast-paced environment. Strong attention to detail and organizational skills. Ability to communicate effectively and build professional working relationships at all levels of the organization. Commitment to maintaining confidentiality and handling sensitive information appropriately. Consistently represents the company with professionalism, tact, and discretion. WHY CHOOSE RELATION? Competitive pay. A safe and healthy work environment provided by our robust benefit program including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays and more. Career advancement and development opportunities. . Note: The above is not all encompassing of the full position description. Relation Insurance Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Relation, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is presented within this posting. You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various factors, including, without limitation, individual and organizational performance. . $0.00 - $0.00