Who's Who in the Claims Office - Know The Players

If you never worked in a workers’ compensation claims office, but have dealt with one or more claim offices, you may have wondered who does what in the claims office. The following is a glossary of claim office positions and the type of work done by the people with these job titles. Every insurance carrier and every third party administrator (TPA) will structure their claim office a little differently. Not all workers’ comp claim offices will have all the claim positions listed here, as each claims organization will be structured to be suit their own business needs.

Claims Clerk

The clerical staff within the claims office is often the engine running the office. The clerical staff is normally responsible for the intake of new claims whether electronic, telephonic or mail, the case creation – “setting up the claim file,” the input of the data into the risk management information system and often, initial contact letters and acknowledgment forms to the state, the employer and the employee. (WCxKitz)

The clerical staff is also responsible for in-coming and out-going mail, matching correspondence to claim file folders (or scanning paper correspondence into the risk management information system) and opening & closing of files. Additionally, a clerical person is responsible for issuing payments, both automatic issues (like weekly indemnity checks) and one-time payments.

Depending on the size of the claims office the clerical staff may be broken down into various levels like Clerk 1, Clerk 2, Clerk 3, Secretary 1, Secretary 2, etc., with pay grade advancements to match their job title growth.

Medical Only Adjuster

The medical only adjuster is often an experienced clerical person who has shown the aptitude and ability to do more than basic clerical work. The medical only adjuster will contact the medical providers to obtain the medical reports and medicals bill. Once the information is available, the medical only adjuster will review the medical bills to ascertain the relationship between the injury and the medical treatment. The medical only adjuster will request payment of the medical bills and verify there will be no further treatment prior to closing the medical only file. A standard workload, depending on the jurisdiction, for a medical only adjuster is to have 350 to 500 open medical only files at any one time.

Adjuster Trainee

Most new adjuster trainees are recent college graduates with a background in insurance, business or a related field. Occasionally, insurers or TPA’s will recognize they have a bright clerical person who does not have a college degree but has shown the intellectual ability to take on the challenge of adjusting claims. (WCxKitz)

The new adjuster trainee will normally go to either an in-house training program or to a specialty school to learn the basics of workers’ comp insurance adjusting. Most states require the adjuster trainee to take a pre-determined number of hours of workers’ compensation class training before they can take the state licensing test.

Once the new adjuster is licensed, the claim office will assign to the adjuster trainee the simple workers’ comp claims. The adjuster trainee is often asked to investigate thoroughly these claims for the experience of learning to contact employers and employees, take statements, investigate the details, etc. The adjuster trainee will have a claims supervisor who will be reviewing the work performed, providing directions and managing the process. A normal workload for an adjuster trainee is 75 to 100 open workers’ comp claims.

Adjuster

The adjuster is the workhorse of the claims office. The workers’ comp adjuster is responsible for the complete claim process including coverage verification, contacts, reserving, investigation, medical management/cost containment, disability management, litigation management, subrogation, subsequent injury fund recovery, disposition and settlement. Also, if the adjuster works for a TPA, the adjuster is responsible for reporting all information to the insurer or principal.

The adjuster is usually the primary contact of the employer with the insurer or TPA. In addition to working with the employees – “claimants” on each claim, the adjuster will build relationships with the various parties involved in the claim including the employers, the medical providers and the attorneys — both plaintiff and defense attorneys. (WCxKitz)

A supervisor will normally review the work of the adjuster on a regular basis, but will not be involved in the decision-making or claims handling process except on the more expensive files and the files with questionable compensability. It is normal for the workers’ comp adjuster to have 125 to 150 open files at any one time. Depending on the insurer or TPA, the adjuster level may be broken down into additional levels like Adjuster 1, Adjuster 2, etc.

Senior Adjuster

The designation senior adjuster is for highly experienced adjusters with many years on the job. These adjusters are masters of the workers’ comp world knowing how to investigate every type of claim, knowing the intricacies of their state workers’ comp laws, and knowing when to settle and when to fight a claim.

The senior adjusters often act as mentors to the adjuster trainees or younger/less-experienced adjusters. The senior adjusters are normally assigned the most difficult claims and the claims with the highest exposure. A normal workload, depending on the jurisdiction, for the senior adjuster is 125 to 150 open claims. (WCxKitz)

Supervisor

The workers’ comp supervisor is responsible for a team of adjusters and the work product produced by those adjusters. The supervisor will normally have three or four adjuster trainees on their team, or four or five adjusters, or five to eight senior adjusters. The supervisor is responsible for making sure the adjusters meet all best practices or service standards on each file.

The supervisor, in addition to day-to-day discussions and directions to the adjusters, will keep the inventory of all claims assigned to them on a diary (also known as a futurity at some companies). A diary is a calendar reminder system. All the files of the adjuster trainees will normally be reviewed by the supervisor every month while the claim files of the adjusters will be reviewed every 60 or 90 days.

Assistant Manager

If the claim office is large enough, it will have an assistant manager between the levels of workers’ comp supervisor and branch manager. The assistant manager is often responsible for assignment of claims to the adjusters, for compliance with regulatory requirements, and management of the workers’ comp supervisors. (WCxKitz)

Branch Manager

The branch manager of the claims office is responsible for everything that goes on in the claims office. The selection and hiring of employees, the workflow of the clerical staff, the prompt and proper resolution of claims, and the liaison between employers and insurers are the responsibility of the branch manager. Ultimately, the successful operation of the claims office lies with the skill level of the branch manager.

Author Rebecca Shafer, Consultant & Attorney, President, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.