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Cigna Senior Workers' Comp Adjuster (Claims Senior Analyst) Qual-Lynx in King of Prussia, Pennsylvania

Senior Workers' Compensation Claims Adjuster

Independently investigates, evaluates, and resolves assigned Workers’ Compensation claims of a more complex or litigated nature in a timely manner in accordance with legal statutes, policy provisions and company guidelines.

Location: This role can be located in Piscataway, NJ; Egg Harbor Twp, NJ; King of Prussia, PA (the role will start remote, then move to partial onsite)

  • Evaluate claimant eligibility; communicate with attending physician, employer and injured worker.

  • Work with both the claimant and their physician to medically manage the claim, from initial medical treatment to reviewing and evaluating ongoing treatment and related information.

  • Work directly with employers to facilitate a return to work, either on a full-time or modified duty basis.

  • Confirm coverage and applicable insurance policy or coverage document and statutory requirements.

  • Identify potential for third party recovery, including subrogation, Second Injury Fund or other fund involvement (when applicable) and excess or reinsurance reimbursement. Pursue the process of reimbursement and complete posting of recovery to the claim file, where appropriate.

  • Identify potential for disability or pension credits or offsets and apply same where appropriate.

  • Ensure timely denial or payment of benefits in accordance with jurisdictional requirements.

  • Establish claim reserve levels by estimating the potential exposure of each assigned claim, establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure.

  • Establish compensability status through case investigation and evaluation and application of jurisdictional statutes and laws.

  • Manage diary in accordance with Best Practices and complete tasks to ensure that cases move to the best financial outcome and timely resolution.

  • Where litigation is filed, evaluate exposure and work with defense counsel to establish strong defenses, prepare litigation plan of action, set legal reserve and manage litigation over life of claim.

  • Close all files as appropriate in a timely and complete manner.

  • Maintain closing ratio as directed by management team.

  • Oversee and coordinate medical treatment for injured employees and provide information to treating physicians regarding employees’ medical history, health issues, and job requirements; provide direction to assigned nurse case manager where applicable.

  • Complete PARs (payment authorization request) when applicable.

  • Comply with all excess and reinsurance reporting requirements; manage self-insured retention reporting.

  • Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account-related issues.

  • Provide a high degree of customer service to clients, including face to face interactions during claim reviews, meetings and similar account-specific sessions.

  • Provide assistance with company education and training.

Requirements include:

  • High School diploma required;

  • Associate’s or Bachelor’s degree preferred, or five or more years of equivalent work experience required in an insurance, medical/health or legal related industry;

  • At least 5-6 years of experience handling workers’ compensation claims required with experience handling litigated and lost time claims.

  • Completion of Workers’ Compensation training courses internally and/or externally in all significant areas affecting Workers’ Compensation claims handling and practices.

  • Workers’ Compensation licenses, certifications, awards preferred.

  • Expertise in Workers’ Compensation and related claims handling practices and ability to apply same; deep knowledge of client and carrier claims procedures; significant understanding of self-insured retention, excess and reinsurance reporting; fluent in medical terminology and medical/injury

  • Proficient with MS Excel and Word; computer experience with related claims

  • Excellent verbal and written communication skills; proven interpersonal skills capable of dealing with all levels of personnel

  • Exceptional ability to multi-task

  • Excellent negotiation skills

  • Superior organizational and decision making skills

  • Customer-focused orientation

  • Strong analytical and strategizing skills

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

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