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When a person is injured while fulfilling job responsibilities for an employer, a workman's compensation claim is usually filed for coverage of medical-related services received as a result of the on-the-job injury. It is the responsibility of a workers' compensation claims adjuster to receive and organize all documents related to the employee and the injury in order to make a determination regarding the claim. Workers' compensation claims adjusters abide by company guidelines when making claim determinations. The guidelines and job duties of a workers' compensation claims adjuster will vary by company.
Upon being injured during an on-the-job incident, the injured employee visits a doctor's office or other health-care facility. The workers' compensation claims adjuster is usually notified of the incident by the employer's human resources person. The workers' compensation claims adjuster contacts the injured employee to obtain an account of the events surrounding the injury. The workers' compensation claims adjuster also requests records from the medical professionals who saw the patient.
Once the workers' compensation claims adjuster has received the appropriate forms from the employer, the employee's statement and the medical records, the adjuster assesses all of the information to determine if the injury was work-related or not. If it is determined that the injury was not work related, the adjuster notifies the employer, employee and health care providers of the determination. The claims process for denied claims usually ends at this point, unless there is an appeal.
Opening and Closing a File
If the workers' compensation claims adjuster determines that the injury was work related and the claim meets all other claims criteria, the adjuster opens a file for the employee. The adjuster will continue to receive all injury-related medical claims on the employee. The adjuster evaluates the claims and forwards them to another department for payment. The adjuster maintains contact with the employee and health-care professionals regarding status of the injury and treatment plans. Once the injured employee is healed and no longer requires treatment, the file is closed.