Workers' Compensation Claims Adjuster I

EMC Insurance Companies

8d•$55,795 - $84,778•Remote

About The Position

The Workers' Compensation Claims Adjuster I reviews and investigates workers' compensation claims, determines coverage and compensability, and manages claims through resolution. The role evaluates medical and wage-benefit information, coordinates return-to-work efforts, pursues recovery opportunities, and communicates claim decisions and status to relevant parties. It also works with attorneys and internal teams to support claim resolution and broader claims initiatives. This position is eligible to work from home anywhere in the United States. Occasional travel is required.

Requirements

Bachelor’s degree or equivalent relevant experience.
One year of workers’ compensation claims adjusting experience or related experience.
Attain all applicable state licenses within one year of hire.
Working knowledge of the theory and practice of the claim function.
Good knowledge of insurance contracts, medical terminology, and substantive and procedural laws.
Ability to adhere to high standards of professional conduct and code of ethics.
Strong knowledge of computers and claims systems.
Strong organizational and written and verbal communication skills.
Good investigative and problem-solving abilities.
Occasional travel is required; a valid driver’s license and an acceptable motor vehicle report per company standards are required if driving.

Nice To Haves

Experience with Oklahoma, Kansas, Arkansas, and Kentucky.
Relevant insurance designations.

Responsibilities

Review claim notices, policies, contracts, and applicable state requirements to determine coverage, jurisdiction, deductibles, and compensability.
Conduct timely investigations by contacting insureds, injured workers, witnesses, and other relevant parties; obtaining statements; and securing reports and documentation.
Document claim activity, maintain accurate file diaries, establish appropriate reserves, and handle claims promptly through resolution.
Review medical records, treatment plans, bills, invoices, and other documentation to understand injuries, evaluate expenses, and coordinate appropriate medical care.
Calculate and administer wage benefits and monitor changes that may affect benefit amounts.
Coordinate return-to-work efforts with injured workers, insureds, medical providers, and other parties.
Identify and pursue recovery and subrogation opportunities; refer claims to specialized resources, including Special Investigation and medical management or review teams, when appropriate.
Investigate and resolve compensability and coverage issues and communicate decisions and claim status to relevant parties.
Prepare settlement evaluations, negotiation strategies, independent medical examination documentation, and denial correspondence as appropriate.
Partner with attorneys and participate in mediations, settlement conferences, and other activities to facilitate claim resolution.
Promote claims programs and resources, including On Call Nurse (OCN), Return to Work (RTW), and Select Preferred Provider (SPP) programs.
Collaborate with Claims, Underwriting, Risk Improvement, and other internal teams, including preparing risk alerts and supporting broader claims initiatives as needed.