Senior Claims Adjuster – Workers' Compensation

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

📋 Description

• Assume responsibility for moderately to highly complex workers' compensation claims from the investigation phase through to resolution.

• Evaluate coverage and verify that losses are included under client policies.

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

• Perform fact-finding investigations and gather recorded statements.

• Create and implement action plans to resolve claims effectively.

• Analyze and uphold appropriate reserves in accordance with client guidelines.

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

• Recognize risk factors and direct claims for specialized handling, such as SIU, subrogation, and medical review.

• Investigate and pursue subrogation opportunities.

• Elevate complex claims and work in collaboration with leadership.

• Prepare necessary jurisdictional filings.

• Assess coverage, liability, and claim value while responding to stakeholder inquiries.

• Negotiate settlements, engage in mediation, and manage payments within authority limits.

• Draft denial and settlement documentation, providing support for litigation, mediation, arbitration, and Medicare compliance.

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

• Stay updated on regulations and maintain required licenses/CEUs.

• Assist with training and mentor team members.

⛳️ Requirements

• Bachelor’s degree or equivalent relevant experience.

• At least five years of claims adjusting experience or related field experience.

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

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

• Workers' compensation claims adjusting experience in IA, MN, NE, SD, IN, KS, MO, WI, or IL is preferred.

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

• Excellent analytical, investigative, and problem-solving skills related to liability and coverage.

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

• Proficient computer skills, including experience with claims systems.

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

• Ability to effectively advise, partner, and consult with diverse internal and external stakeholders.

• Occasional travel is required.

• Valid driver’s license with an acceptable motor vehicle report as per company standards.

🏝️ Benefits

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

• Remote work opportunities from anywhere in the United States.

• Tobacco-free workplaces and company vehicles.