Job Description
Job Description
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.