Senior Claims Adjuster – WC

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Assume full responsibility for moderately to highly intricate workers’ compensation claims from the investigation phase to resolution.

• Assess coverage, liability, compensability, treatment, claim value, and the applicability of policies.

• Establish contact with clients, claimants, employees, and medical providers within 24 hours.

• Conduct fact-finding, investigations, and obtain recorded statements.

• Create and implement action plans for efficient claims resolution.

• Perform reserve analysis and establish or uphold suitable reserves.

• Review medical records and bills thoroughly.

• Identify and pursue opportunities for risk, recovery, and subrogation.

• Direct claims for specialized handling, including SIU, subrogation, and medical review.

• Escalate complex claims and engage in collaboration with leadership.

• Prepare jurisdictional filings, denial documentation, settlement documentation, and claim evaluations.

• Negotiate settlements, take part in mediation, and manage payments within authorized limits.

• Assist with litigation, mediation, arbitration, and ensure Medicare compliance.

• Maintain diaries and action plans, provide updates on claims, conduct consultations with clients, coordinate with vendors, and manage reporting.

• Stay informed on regulations and maintain necessary licenses and continuing education units (CEUs).

• Mentor and assist in the training of team members.

⛳️ Requirements

• Bachelor’s degree or equivalent relevant experience.

• A minimum of five years of claims adjusting experience or related experience.

• Previous experience with a third-party administrator (TPA) is preferred.

• Coursework or designations in INS, AIC, SCLA, WCLA, and CPCU are preferred.

• Experience in workers' compensation claims adjusting in FL, GA, NC, or SC is preferred.

• Exceptional knowledge of the theory and practice of claims functions.

• Strong analytical, investigative, and problem-solving skills regarding liability and coverage.

• Comprehensive knowledge of insurance contracts, medical terminology, and legal aspects of court procedures impacting legal liability.

• Proficient computer skills, including familiarity with claims systems.

• Strong organizational, written, and verbal communication skills, including documentation capabilities.

• Ability to advise, partner, and consult with a diverse range of internal and external stakeholders.

• Possession of a valid driver’s license with an acceptable motor vehicle report according to company standards.

🏝️ Benefits

• Comprehensive rewards package; benefits details provided at www.emcins.com/careers.

• Opportunity to work from home.

• Occasional travel may be required.

• Tobacco-free workplaces and company vehicles.