Senior Claims Adjuster, Workers' Compensation

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

📋 Description

• Assume full responsibility for managing moderately to highly complex workers’ compensation claims from initiation to resolution.

• Evaluate coverage to ensure that losses are encompassed under client policies.

• Establish contact within 24 hours with all relevant stakeholders.

• Conduct thorough fact-finding, recorded statements, and comprehensive claim investigations.

• Create and implement action plans to resolve claims in an efficient manner.

• Perform reserve analysis and set or adjust appropriate reserves as necessary.

• Review medical records and bills to evaluate injury, compensability, treatment, and accuracy.

• Identify risk factors and direct claims for specialized management.

• Investigate and seek out subrogation opportunities.

• Escalate complex claims and work collaboratively with leadership.

• Prepare necessary jurisdictional filings.

• Assess coverage, liability, and claim value.

• Negotiate settlements, engage in mediation, and oversee payments within authorized limits.

• Draft denial and settlement documentation and assist with litigation, mediation, arbitration, and Medicare compliance.

• Maintain diaries and action plans, provide claim updates, conduct client consultations, coordinate vendor resources, and manage reporting.

• Keep up-to-date with regulations, maintain licenses/CEUs, assist with team training, mentor colleagues, and enhance team performance.

⛳️ Requirements

• Bachelor’s degree or equivalent relevant experience is required.

• Minimum of five years of claims adjusting experience or related experience is essential.

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

• Completion of INS, AIC, SCLA, WCLA, and CPCU coursework or designations is preferred.

• Workers' compensation claims adjusting experience in California is preferred.

• Strong understanding of the theory and practice surrounding the claims function.

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

• In-depth knowledge of insurance contracts, medical terminology, and legal aspects of court procedures impacting legal liability across all lines of insurance.

• Proficient computer skills, including familiarity with claims systems.

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

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

• Occasional travel may be required.

• Valid driver’s license with an acceptable motor vehicle report according to company standards.

• Capability to maintain licenses/CEUs.

🏝️ Benefits

• Comprehensive rewards package.

• Opportunity to work remotely from anywhere in California.

• Occasional travel opportunities.

• Tobacco-free workplaces and company vehicles.