Claims Adjuster

This is a fully remote position, open to applicants in California.

📋 Description

• Oversee all facets of workers' compensation claims throughout their entire lifecycle.

• Assess compensability and confirm coverage.

• Manage disability and medical benefits.

• Negotiate claim resolutions and provide assistance to injured employees, employers, and medical/legal professionals.

• Receive newly filed claims and ensure claim notes are up-to-date.

• Enter claim details into an electronic database.

• Conduct interviews with claimants, insured parties, medical professionals, and witnesses to validate claims.

• Communicate decisions regarding claim compensability to claimants, employers, and medical providers.

• Establish appropriate reserves based on the nature and severity of injuries.

• Calculate lost-time wages, facilitate disability payments, and schedule future payment reminders.

• Request independent medical examinations and prepare documentation for physician evaluation.

• Maintain regular correspondence with claimants, insured parties, and nurse case managers about claim status, appointments, and disability payment concerns.

• Review and process medical bills through a third-party vendor to explore discount opportunities.

• Collaborate with claimants and insured parties to facilitate early return-to-work initiatives.

• Work alongside legal counsel on litigated claims, providing necessary documentation for defense and exposure assessment.

• Attend settlement conferences, mediations, and hearings representing the insurance company or insured parties.

• Review and authorize defense attorney bills within the scope of authority.

• Collaborate with underwriting on loss data for renewal rates and with Risk Management to identify trends.

• Engage with insured agents regarding losses as required.

• Address state inquiries related to health-cost disputes, hearing applications, and penalty assessment notices.

• Identify potential for subrogation and pursue recovery efforts.

• Lead claim reviews with clients upon request.

• Perform additional responsibilities as assigned.

⛳️ Requirements

• A minimum of 10 years of experience in adjusting Workers' Compensation Claims in California is essential.

• SIP Certification is mandatory.

• Bilingual proficiency in Spanish and English is required.

• Must be up-to-date with Continuing Education Units (CEUs).

• Proficient in the complete Microsoft Office suite.

• Familiarity with relevant workers' compensation laws is necessary.

• Strong understanding of medical terminology is required.

• Knowledge of medical cases and typical treatment progressions is important.

• Exceptional verbal and written communication skills are a must.

• Attention to detail and strong organizational skills are essential.

• Proven ability to negotiate issues and settlements effectively.

• Strong customer service orientation, including prompt responses to requests and inquiries.

• Capability to adapt to evolving technologies and learn new equipment and systems.

• Ability to establish and maintain effective working relationships with colleagues and clients.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance plans.

• Retirement savings plan with employer matching contributions.

• Paid time off and flexible work arrangements.

• Opportunities for professional development and continuing education.