Senior Claims Adjuster – Workers' Compensation
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Job Description
Senior Claims Adjuster managing complex workers’ compensation claims for EMC insurance clients. Investigating coverage, setting reserves, negotiating settlements, and guiding claims to resolution.
Responsibilities:
- Take ownership of moderately to highly complex workers' compensation claims from investigation through resolution
- Analyze coverage and confirm losses are covered under client policies
- Initiate contact within 24 hours with clients, claimants, employees, and medical providers
- Conduct fact-finding investigations and obtain recorded statements
- Develop and execute action plans to resolve claims efficiently
- Analyze and maintain appropriate reserves according to client guidelines
- Review medical records and bills to assess injury, compensability, treatment, and accuracy
- Identify risk factors and route claims for specialized handling, including SIU, subrogation, and medical review
- Investigate and pursue subrogation opportunities
- Escalate complex claims and collaborate with leadership
- Prepare required jurisdictional filings
- Evaluate coverage, liability, and claim value and respond to stakeholder inquiries
- Negotiate settlements, participate in mediation, and manage payments within authority limits
- Prepare denial and settlement documentation and support litigation, mediation, arbitration, and Medicare compliance
- Maintain diaries and action plans, provide claim updates, conduct client consultations, coordinate vendors, and manage reporting
- Stay current on regulations and maintain licenses/CEUs
- Support training and mentor team members
Requirements:
- Bachelor’s degree or equivalent relevant experience
- Five years of claims adjusting experience or related experience
- Prior experience with a third party administrator (TPA) preferred
- INS, AIC, SCLA, WCLA and CPCU coursework or designation preferred
- Workers' compensation claims adjusting experience in IA, MN, NE, SD, IN, KS, MO, WI, or IL preferred
- Excellent knowledge of the theory and practice of the claim function
- Excellent analytical, investigative, and problem-solving abilities regarding liability and coverage
- Thorough knowledge of insurance contracts, medical terminology, and legal aspects of court procedures affecting legal liability
- Strong computer skills, including claims systems
- Strong organizational, written, and verbal communication skills, including documentation
- Strong ability to advise, partner, and consult with diverse internal and external stakeholders
- Occasional travel required
- Valid driver’s license with an acceptable motor vehicle report per company standards
Benefits:
- Comprehensive rewards package; benefits details provided via www.emcins.com/careers
- Remote work from home anywhere in the United States
- Tobacco-free workplaces and company vehicles
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