Description
Investigate, evaluate, and resolve workers' compensation claims to determine compensability, benefits, and settlement in accordance with state statutes and company procedures; coordinate medical management and return-to-work efforts; and collaborate with legal counsel on litigated files.
- • Review first notice of injury, policy details, and jurisdiction to confirm coverage and employment relationship.
- • Analyze investigation and medical evidence to determine compensability and benefit entitlement.
- • Review medical records, bills, diagnostics, and accident reports to assess causation and disability.
- • Evaluate treatment plans against guidelines and fee schedules; authorize, dispute, or redirect care as appropriate.
- • Conduct recorded statements and interview injured workers, employers, and witnesses to clarify facts.
- • Inspect accident scenes or coordinate field investigations when needed.
- • Calculate average weekly wage and compensation rates; verify earnings and concurrent employment.
- • Set and adjust indemnity, medical, and expense reserves in line with exposure and company policy.
- • Issue timely TTD/TPD/PPD, mileage, and medical payments within authority and statutory deadlines.
- • Coordinate nurse case management, IMEs, peer reviews, and other vendors to drive outcomes.
- • Identify red flags and refer potential fraud to SIU; escalate complex issues to defense counsel.
- • Verify and reconcile medical bills and liens to ensure accuracy and compliance with fee schedules.
- • Maintain detailed claim notes, diaries, and documentation in the claims system.
- • Prepare and submit required jurisdictional notices and EDI filings (FROI/SROI) on time.
- • Develop and monitor return-to-work and light-duty plans with employers and vocational resources.
- • Pursue subrogation against responsible third parties and protect the carrier's lien.
- • Collect and preserve evidence, including wage records and incident reports, to support decisions.
- • Confer with defense counsel on litigated files and develop strategies and budgets.
- • Attend depositions, mediations, hearings, or trials as needed.
- • Present high-exposure cases at claim reviews and committee meetings.
- • Negotiate stipulations, compromise and release agreements, or structured settlements within authority.
- • Report overpayments, underpayments, penalties, and other irregularities and implement recovery plans.
- • Communicate regularly with injured workers, employers, medical providers, and agents to move files to resolution.
- • Ensure compliance with state workers' compensation statutes, case law, and company procedures.
- • Review field, nurse, and SIU reports and authorize further investigation when warranted.
- • Monitor and manage litigation and allocated loss adjustment expenses to control costs.
- • Notify excess or reinsurance carriers of qualifying losses and provide status updates.
- • Generate internal reports and recommendations on claim status, reserves, and settlement strategy.
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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This site includes information from O*NET by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA), used under the CC BY 4.0 license. Career Clutch has modified some of this information for student readability. USDOL/ETA has not approved, endorsed, or tested these modifications. O*NET® is a trademark of USDOL/ETA.
Last reviewed: Jan 2026
