Senior Claims Adjuster (Workers' Compensation)
About The Position
At EMC, team members work together to make an impact, grow, contribute, and gain meaningful experience. The company aims to be caring leaders, close partners, and responsive experts who support one another. The Senior Claims Adjuster takes ownership of moderately to highly complex workers’ compensation claims and impacts outcomes for clients and claimants. The role drives investigations, evaluates coverage and liability, and shapes claim strategies through resolution. Responsibilities include setting reserves, negotiating settlements, identifying risks and recovery opportunities, maintaining client and stakeholder relationships, complying with evolving regulations, mentoring others, and supporting team performance. This position is eligible to work from home anywhere in the United States, with occasional travel required.
Requirements
- Bachelor’s degree or equivalent relevant experience.
- Five years of claims adjusting experience or related experience.
- Excellent knowledge of the theory and practice of the claim function.
- Excellent analytical, investigative, and problem-solving abilities related to liability and coverage.
- Thorough knowledge of insurance contracts, medical terminology, and legal aspects of court procedures affecting legal liability for all lines of insurance.
- Strong computer skills, including experience with claims systems.
- Strong organizational, written, and verbal communication skills, including documentation.
- Ability to advise, partner, and effectively consult with diverse internal and external stakeholders.
- A valid driver’s license and an acceptable motor vehicle report under company standards.
Nice To Haves
- Prior experience with a third-party administrator (TPA).
- INS, AIC, SCLA, WCLA, or CPCU coursework or designation.
- Workers’ compensation claims adjusting experience in IA, MN, NE, SD, and IN, or in IA, KS, MO, WI, and IL.
Responsibilities
- Analyze coverage to confirm losses are covered under client policies.
- Initiate contact within 24 hours with relevant parties, including clients, claimants, employees, and medical providers.
- Conduct thorough investigations, including fact-finding and recorded statements.
- Develop and execute action plans to resolve claims efficiently.
- Perform reserve analysis and set and maintain appropriate reserves according to client guidelines.
- Review medical records and bills to assess injury, compensability, treatment, and accuracy.
- Identify risk factors and, with approval, route claims for specialized handling such as SIU, subrogation, or medical review.
- Identify, investigate, and pursue subrogation opportunities, including reviewing official reports.
- Escalate complex claims and collaborate with leadership as needed.
- Prepare required jurisdictional filings for workers’ compensation claims.
- Evaluate coverage, liability, and claim value, and respond to stakeholder inquiries.
- Negotiate settlements, participate in mediation, and manage payments within authority limits; recommend higher-value settlements.
- Prepare and issue denial and settlement documentation, develop evaluation ranges, and support litigation, mediation, arbitration, and Medicare compliance.
- Maintain diaries and action plans, provide timely responses and claim updates, conduct client consultations, coordinate vendor resources, and manage reporting, including to excess carriers.
- Stay current on regulations, maintain licenses and continuing education credits, and support training of team members.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
