Complex Claims Adjuster

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

📋 Description

• Manage all facets of catastrophic and large loss workers’ compensation claims from initiation to resolution independently.

• Perform prompt 3-point contact investigations and ongoing inquiries as case details evolve.

• Make compensability determinations in accordance with statutory guidelines.

• Establish and modify reserves within authorized limits.

• Present claims to senior management along with internal and external stakeholders.

• Oversee the administration of statutory medical and indemnity benefits throughout the claim's lifecycle.

• Adhere to statutory guidelines, regulations, and rules.

• Supervise defense counsel, litigation activities, legal fees, and associated costs.

• Identify opportunities for early resolution, assess claim exposure, and negotiate settlements.

• Mitigate complex exposures while facilitating favorable outcomes.

• Act as a liaison for partner agents and customers, offering claim guidance and clarifying process expectations.

• Provide updates on claim status, coverage verification, and loss run reports.

• Enhance claims operations, service processes, standard operating procedures, protocols, and workflows.

• Direct proactive litigation strategies and evaluate settlement values using rated ages, present value, Medicare set-asides, medical cost projections, and structured settlements.

• Secure annuity and structured settlement quotes and obtain settlement authority.

• Attend both virtual and face-to-face mediations, informal settlement conferences, and trials.

• Participate in Claims Roundtable meetings and formulate collaborative action plans.

• Generate claims status reports and present updates on large loss cases.

• Collaborate with the Complex Claims Practices Consultant and Claims Leadership to enhance claims operations.

⛳️ Requirements

• A High School Diploma or equivalent is mandatory.

• A Bachelor's Degree or equivalent experience with some college coursework is preferred.

• At least 7 years of experience in workers’ compensation claim adjusting is required (carrier background preferred).

• A minimum of 2 years of experience handling catastrophic claims.

• Capability to assess and identify high dollar, high exposure, complex claims.

• Strong claims handling expertise within the Southeast region is preferred, particularly in Florida, Georgia, and/or North Carolina.

• Willingness to broaden jurisdictional knowledge and acquire additional state licenses as business needs change.

• Active licensing in relevant states is required.

• Excellent communication skills, both written and verbal.

• Strong problem-solving abilities.

• In-depth knowledge of jurisdictional regulatory and statutory requirements, including CMS/MSA requirements.

• Extensive experience in claim adjudication, medical, and litigation management.

• Advanced analytical skills to take necessary action across multiple focus areas based on various data points.

• Ability to make claim decisions that mitigate exposure while ensuring optimal outcomes.

• Skills to resolve conflicts effectively and achieve beneficial results.

• Capability to mentor junior adjusters.

• Experience with G-Suite Tools and collaboration platforms like Slack is preferred.

🏝️ Benefits

• Competitive cash compensation

• Comprehensive health plans

• Generous PTO

• Future-focused 401k match

• Generous parental and caregiver leave

• Discretionary bonuses may be awarded annually to eligible team members