Sr Claims Adjuster (Workers' Compensation)

Basic Function

Responsible for investigating and administering assigned Workers’ Compensation claims and when warranted pursue litigation and subrogation against third parties. Performs duties in a safe, efficient manner and in compliance with applicable rules and safety procedures.

Responsibilities and Specific Duties

• Reviews facts, establishes liability, evaluates damages and negotiates appropriate settlements within the authority granted, including claims committee monetary evaluations based upon all known facts.
• Investigates, administers, and pays medical and indemnity benefits (TIBS, IBS, SIBS, LIBS) in accordance with the Texas Workers’ Compensation Act.
• Evaluates claims according to Workers’ Compensation Labor code and administers day to day activities while claim is active.
• Sets appropriate financial reserves and maintains adequate funding throughout the life of the claim file.
• Reviews files, maintains claims notes, and makes timely payments based on electronic diaries.
• Takes recoded statements from involved parties and explains the Workers’ Compensation benefits and procedures as needed.
• Requests indexing of all injured parties as well as confirms status with Centers for Medicaid and Medicare Services (CMS).  Requests damage appraisals, police reports, medical bills, medical reports, and wage information.
• Maintains contact with all parties regarding claims (i.e., doctors, employees and line supervisors).
• Coordinates claims investigation with the liability claims team to avoid duplication of processes.
• May be required to represent METRO at hearings as required by the Texas Department of Insurance/Division of Workers’ Compensation (TDI/DWC).  Provides information required by TDI/DWC, attorneys, DWC hearing representatives and other involved parties.
• Works with internal and external parties including leadership to transfer and receive information regarding the claim file.
• Processes all DWC and PLN Forms (Employer & Carrier) in accordance with TDI/DWC deadlines.
• Processes all claim data DWC and PLN forms to the State for Electronic Interface Data (EDI) Forms are manually entered into Metro’s EDI vendor’s file.  Must monitor the successful return of the electronic data confirmation.
• Schedules return to work physicals and drug screens along with processing the required forms for employees who return to work from claims.
• Manages vendor or attorney regarding subrogation recovery.
• Provides excellent customer service to METRO internal and external customers.
• Applies SMS (Safety Management System) methods and principles in daily routine and supports all aspects of the agency’s Public Transportation Agency Safety Plan (PTASP).
• Promotes safety awareness and follows safety procedures to reduce or eliminate accidents.
• Performs other job-related duties as assigned.

Education Requirement

High School Diploma or GED is required. Bachelor’s degree in Risk Management, Finance or Business Administration preferred.

Years & Experience Required

Minimum five (5) years progressively responsible Workers’ Compensation and/or Litigation claims experience. Bilingual preferred.

Knowledge & Skills Required

Excellent analytical skills in researching and reviewing negligence accident reports, statements or interrogatories, medical bills, indexes and medical narratives.  Good communications (written and verbal) skills. Must have an understanding of legal insurance and medical terminology and functional knowledge of Texas Tort Claims Act and/or Texas Workers’ Compensation Act. Texas Insurance Adjusters license in one of these types; Texas Property and Casualty or a Texas All Lines license is required.

Additional Information

The Metropolitan Transit Authority of Harris County, Texas has a zero tolerance drug and alcohol policy for all employees. All internal and external applicants will be required to undergo drug testing before employment and will be subject to further drug and/or alcohol testing throughout their employment.

Further, employees who perform safety-sensitive functions will submit to drug and/or alcohol testing in accordance to the Department of Transportation (DOT) and the Federal Transit Administration (FTA) regulatory requirements.

We provide equal opportunity to all qualified individuals regardless of race, color, religion, age, sex, national origin, veteran status, genetic information or disability.

Pay Range: $68,000 - $89,300

This is an on-site position.