Experienced Claims Adjuster

Role Overview

• Conducts the investigation of reported claims via three-point contact calls to determine coverage, compensability and severity, and to gather all other relevant information, documenting all relevant information thoroughly and escalating the investigation for further investigation when appropriate.
• Calculates appropriate reserves for each claim and ensures that reserves are adjusted as needed per authority guidelines.
• Calculates and administers benefits in accordance with statutory requirements, including timely issuance of appropriate notices and filings.
• Develops and updates a Plan of Action for the successful resolution of each claim; timely updates Plan as new information is obtained.
• Makes prompt, sound decisions on issues that arise in claims based on the best information available, ensuring that work is performed in accordance with Company standards, training, supervisory direction, and applicable laws. Timely escalates issues/red flags to Supervisor and/or appropriate internal team.
• Ensures that the actions of all other professionals involved in claim, including attorneys, nurse case managers, and investigators, are coordinated to achieve a successful resolution of the claim.
• Assigns appropriate tasks to a Claims Assistant and/or Claims Clerical Assistant and ensures they are performed correctly and efficiently.
• Accurately and thoroughly prepares litigation referrals, AOE/COE investigation referrals, and MSA referrals for submission to vendor; obtains proper approval from Management.
• Prepares timely and accurate settlement recommendations (within designated authority parameters) and effectively negotiates settlement of claims.
• Fosters a positive and close working relationship with partner company staff, including the Call Center, Medical Management, Special Investigations, Client Services, Underwriting, and Claims Legal.
• Communicates effectively with individuals outside the company, including clients, medical providers, and injured workers.
• Collaborates with Adjusting staff and relevant interdepartmental personnel on special projects focused on process efficiency.
• Ensures continual education requirements are met.

Requirements

• EDUCATION: Minimum of a High School diploma required or equivalent certificate required; Bachelor's degree from four-year College or university preferred.
• DESIGNATION: Designated as a Claims Adjuster or Experienced Claims Adjuster per the California Code of Regulations and has completed the minimum required continuing education credits to adjust workers compensation claims for the State of California; Self-Insured certification a plus.
• EXPERIENCE: Minimum of three years of indemnity adjusting experience managing large and/or complex claims and accounts within a workers’ compensation carrier required
• Inquisitive, critical thinker; agile learner with adaptive, smart time management skills.
• To perform this job successfully, an individual should be proficient in the Microsoft Office Suite of applications (highly proficient in Excel preferred), and be proficient on applicable databases, systems and vendor software programs.

Benefits

• Work-Life Balance
• Work From Home Program (up to 2 days per week)
• Reasonable caseload with in-house Medical Management support (UR, Med Bill Review, Resource Nurses); In-house Claims Assistant support
• Free On-Site Fitness Facility
• Free On-Site Garage Parking
• Paid Time Off
• Paid Holidays
• Retirements Savings Match
• Group Health Insurance (Medical, Dental, and Vision)
• Life and AD&D Insurance
• Long Term Disability Insurance
• Accident and Critical Illness Insurance
• Flexible Savings Accounts
• Paid Community Volunteer Day
• Employee Assistance Program
• Tuition Reimbursement Program
• Employee Referral Program
• Diversity, Equity and Inclusion Program