Senior Claims Adjuster - Workers Compensation

PMA Companies•Roseville, CA

6d•Remote

About The Position

As a member of the claims team, the Senior Claims Adjuster uses Workers Compensation expertise to independently investigate, evaluate, and resolve assigned claims, including complex and highest-risk claims. The role administers claims in a timely manner in accordance with applicable statutes, policy provisions, and company guidelines, and works to achieve appropriate outcomes.

Requirements

Bachelor's degree or at least four years of equivalent work experience in an insurance-related industry.
At least 3–5 years of experience handling lost-time Workers Compensation claims.
Past experience with California jurisdiction.
Active license or ability to obtain a license within 90 days of employment in mandated states.
Familiarity with medical terminology and/or Workers Compensation.
Strong organizational skills and ability to work independently while managing multiple tasks.
Critical-thinking, analytical, judgment, and decision-making skills, with attention to detail.
Strong verbal and written communication and customer service skills.
Computer literacy, including working knowledge of Microsoft Office products such as Word, Excel, and PowerPoint.
Ability to travel for business purposes, approximately less than 10%.

Nice To Haves

Associate in Claims (AIC) designation or similar professional designation.

Responsibilities

Promptly investigate assigned claims, including complex claims, with minimal supervision.
Determine coverage, compensability, potential subrogation recovery, and second injury fund applicability.
Alert the Supervisor and Special Investigations Unit to potentially suspicious claims.
Ensure timely denial or payment of benefits in accordance with jurisdictional requirements.
Establish appropriate reserves with documented rationale and maintain or adjust them as claim exposure changes.
Negotiate claim settlements with client approval.
Establish and implement case-resolution plans, including medical and disability management, litigation management, negotiation, and disposition.
Collaborate with PMA nurse professionals to develop and execute return-to-work strategies.
Select and manage service vendors to balance allocated expenses and loss outcomes.
Maintain knowledge of jurisdictional requirements and applicable case law in each state serviced.
Apply best claim practices consistently and in a timely manner.
Communicate effectively with internal and external parties about claims and account issues.
Provide customer service to clients, including face-to-face participation in claims reviews, stewardship meetings, and similar account-specific sessions.
Authorize treatment according to protocols established by statute or the PMA Managed Care department.
Assist PMA clients with panel-provider information in accordance with applicable state statutes.
Follow the Company's Code of Business Conduct and Ethics and apply relevant compliance policies, procedures, standards, and laws.