Workers Compensation Claims Adjuster I

About the Role

As a Workers’ Compensation Claims Adjuster I at AvonRisk, you’ll manage a caseload of medical only WC claims under close supervision. Your focus is on timely investigation, appropriate medical bill review, utilization management, and driving claims to resolution, without the indemnity complexity. You’ll have experienced mentors, clear guidance, and real responsibility from day one, with exposure to a diverse range of claim types and industries. Medical only claims represent an ideal entry point for developing strong WC fundamentals.

Location & Work Arrangement

Candidates should be based in Texas but are able to work fully remote.

Key Responsibilities

Claims Investigation & Compensability

• Conduct three-point contact with the injured worker, employer, and treating physician within required timeframes to initiate the claim and gather essential facts.
• Assess compensability, evaluate mechanism of injury, and make benefit determinations in accordance with applicable state WC statutes; escalate questionable AOE/COE claims for SIU referral when appropriate.
• Maintain accurate claim documentation and ensure claims are properly classified as medical-only throughout their life cycle.

Medical Management

• Direct medical care throughout the life of the claim, including maintaining medical control where applicable and objecting to unnecessary or unreasonable treatment.
• Coordinate with AvonRisk’s dedicated utilization review and medical bill review teams, providing claim context and following through on their determinations.
• Monitor injured workers’ progress toward maximum medical improvement (MMI) and coordinate with treating physicians to facilitate timely return-to-work outcomes.
• Identify claims at risk of escalating to indemnity status and flag for timely supervisory review.

Reserving & Reporting

• Establish initial reserves based on investigation findings; monitor and adjust at periodic intervals and submit 90-day carrier status reports in compliance with client and regulatory requirements.

Settlements & Recovery

• Negotiate and finalize claim settlements including lien resolution in alignment with client authority; identify and manage subrogation opportunities, coordinating with recovery specialists as needed.

Requirements & Tech Stack

Qualifications

• 1–3 years of experience as a WC Claims Assistant, Trainee, or Future Med Adjuster; OR
• Bachelor’s degree and a minimum of six months of WC claims experience.

Licenses & Certifications

• Active Texas Worker's Comp or all lines license required; multi-state preferred.
• Designation such as AIC, ARM, SIP, or WCCP a plus but not required.

Technical Skills

• Familiarity with claims management platforms (e.g., Guidewire, Juris, ClaimCenter) preferred.
• Working knowledge of Texas WC statutes; proficiency in Microsoft Office Suite; ability to read and interpret medical records.