Claims Adjuster Jobs

About The Position

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.