Senior Claims Adjuster

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

📋 Description

• Oversee intricate workers' compensation claims and assist in assessing benefits owed to injured employees.

• Ensure that ongoing claim adjudication aligns with company standards, industry best practices, as well as statutory and regulatory requirements.

• Reach out to employers, injured workers, and medical providers within 24 hours for newly reported lost-time claims.

• Finalize claim determinations, acceptance or denial letters, wage determination letters, appeal forms, regulatory notifications, and ensure prompt benefit payments.

• Establish and record average or estimated wages, and reconcile payments once verified wages are received.

• Approve or reject medical bills within 24 hours while ensuring timely repricing and payment.

• Identify medical providers and treatment plans, and assign nurse case managers for complex or atypical medical care.

• Document communications, determinations, and correspondence in the claims system; scan and upload documents in a paperless office environment.

• Manage the legal aspects of claims and allocate tasks to designated attorneys.

• Initiate investigations, including surveillance, medical surveys, and social media inquiries, as necessary.

• Ensure that legal, managed-care, and other expense bills are paid promptly.

• Respond to phone calls, voicemails, and emails within specified timeframes.

• Supervise claims assistants and clerical staff on tasks including document copying, medical appointment scheduling, and filing.

• Develop a Plan of Action for each claim and update it on a monthly basis.

• Monitor claims for reinsurance or excess insurance reporting and provide initial and quarterly reports.

• Execute other assigned tasks and responsibilities.

⛳️ Requirements

• High school diploma or GED is mandatory.

• A bachelor’s degree or equivalent experience is preferred.

• At least 5 years of claims experience is preferred.

• Knowledge of the insurance industry is required.

• Exceptional analytical abilities.

• Strong verbal and written communication skills.

• Excellent organizational skills.

🏝️ Benefits

• Comprehensive health insurance.

• Retirement savings plan with company match.

• Generous paid time off policy.

• Opportunities for professional development and advancement.