Claims Adjuster/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 Adjuster/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. This is a 100% fully remote 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 • Evaluate Independent Medical Examination (IME) reports for accuracy and compliance • 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 (New York State required) • 3 - 5 years of claims management experience • Must have experience with filing FROIs and SROIs • Must have EDI filing 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.