Claims Examiner

Jones Jones LLC is a trusted leader in workers’ compensation defense, claims management, and regulatory compliance. With decades of industry experience, we proudly serve clients through our affiliated entities - NYTIC, Emerald, Mediation Resolution Management, and Medical Management Group - offering innovative solutions, collaborative teamwork, and unwavering professionalism. Our firm values growth, integrity, and excellence across every level of our organization.

We are seeking an experienced Claims Examiner who is interested in growing and expanding their expertise across multiple entities, including NYTIC, Emerald, Mediation Resolution Management and Medical Management Group. This unique cross-functional role offers exposure to complex claims, compliance, and ADR operation. This role is perfect for a skilled examiner seeking to broaden scope, strengthen leadership, and grow within a premier workers’ compensation firm.

The Firm is located at 5 Hanover Square, New York, NY and this is a hybrid position.

Essential Functions

1. Claims Adjusting Work (NYTIC / Emerald):

• Perform intake and coverage verification via WCB employer coverage search
• Initiate three-point contact (employer/clamant/provider) within 24 hours
• Conduct compensability analysis and develop action plans
• Ensure timely filings: employer first report, EDI FROI/SROI via Emerald, PH-16.2, and C-240 wage statement
• Calculate AWW and benefit rates; set and review reserves at key milestones
• Monitor treatment against NY Medical Treatment Guidelines; manage MG-2 variance requests and C-8.1 objections
• Route medical bills to bill review and ensure fee schedule compliance
• Prepare for hearings and maintain eCase updates
• Evaluate resolution paths (SLU, LWEC, Section 32); manage subrogation and third-party notices

2. Licensing & Compliance (Jones Jones):

• Collaborate with the Compliance team on licensing forms and regulatory filings
• Review TPA scorecards and ensure compliance with WCB standards
• Track and invoice licensing fees and renewals
• Support examiner training and respond to licensing-related inquiries

3. ADR (MRM):

• Manage intake, eligibility, and notices under the collectively bargained ADR program
• Coordinate and schedule mediations
• Draft case summaries and settlement proposals
• Ensure adherence to Medical Network protocols and document variances
• Prepare and route settlement paperwork, including Section 32 agreements
• Maintain dashboards of ADR cycle times and outcomes for annual reporting
• Obtain loss runs from wrap-up sponsors

4. MMG

• Assist with administrative tasks such as schedule coordination and provider panel management

Competencies

• Excellent and professional verbal and written communication skills
• Strong understanding of workers’ compensation best practices
• Exceptional organizational skills and attention to detail
• Excellent time management skills with a proven ability to meet deadlines
• Strong analytical and problem-solving skills
• Ability to perform well in a fast-paced, dynamic environment
• Ability to maintain confidentiality and exercise discretion and sound judgment
• Proficient with Microsoft Office Suite or related software

Qualifications

• Bachelor’s degree in business administration or related field
• Active Independent Adjuster License (required)
• 2- 5 years of claims management experience

Apply today to join a firm with over a century of success and a future focused on innovation. Jones Jones LLC is an equal employment opportunity employer.