CA - Senior Claims Adjuster, Worker's Compensation

The Senior Claims Adjuster will play a critical role in delivering quality claim file management and an industry-leading customer claims experience., This will be completed by adhering to Pie’s Claims Best Practices and complying with regulatory and statutory requirements. This role will work with internal and external partners to deliver best in class performance, identify and pursue claim mitigation opportunities and deliver favorable claim outcomes for Pie’s customers.

How You’ll Do It

Claims Technical Management:

• Independently handle all aspects of the workers’ compensation claims from set-up to closure.
• Evaluate and handle high dollar, high exposure, complex claims.
• Conduct timely 3-point contact investigation, with focus on continued investigation as facts of the case change.
• Mitigate the complex exposure while achieving the best outcome.
• Determine timely and accurate compensability decisions within statutory requirements.
• Set and adjust timely/accurate reserves within authority limits to ensure reserving activities are consistent with the case facts and company best practices.
• Ability to present claims to senior management, internal and external stakeholders.
• Timely administration of statutory medical and indemnity benefits throughout the life of the claim.
• Comply with all applicable statutory guidelines, rules, and regulations.
• Control legal activity with defense counsel through the litigation process while managing legal fees and costs.
• Prioritize early resolution opportunities, evaluate claim exposure and negotiate settlement.

Claims Customer Service:

• Serve as a point of contact for our partner agents and customers to provide general claim guidance and help set claim process expectations.
• Assist as necessary in providing claim status to agents and insureds, coverage verification and loss run reports, etc.
• Provide excellent customer service to internal and external customers and business partners.
• Advocate to ensure that Pie has a leading claims customer experience.
• Work to continuously improve our claims operations and look at opportunities and gaps in claim service, handling SOPs, protocols and processes.

The Right Stuff

• High School Diploma or equivalent is required.
• Bachelor's Degree or equivalent experience with some college coursework is preferred.
• Minimum of 5-years workers’ compensation claim adjusting experience is required (carrier background, preferred).
• Claims experience handling California WC claims is required.
• Ability to evaluate and identify high dollar, high exposure, complex claims.
• Requires active licensing in applicable states Strong communication (written and verbal) skills, to deliver more complex information effectively.
• Strong problem-solving skills to be able to manage complex tasks and work through to solutions with little guidance and direction.
• Awareness of your own tasks and how it impacts the team and deliverables.
• Experience using G-Suite Tools and collaboration tools like Slack is preferred.
• Advanced knowledge of jurisdictional regulatory and statutory requirements and CMS/MSA requirements.
• Advanced knowledge and experience in claim adjudication, medical, and litigation management.
• Advanced ability to analyze and take necessary action in multiple focus areas based on several data points.
• Ability to make claim decisions to mitigate exposure while achieving the best outcome.
• Ability to use skills to overcome conflict and reach beneficial outcomes.
• Ability to mentor junior adjusters.

The use of AI in Application Review: To support a fair, efficient, and consistent hiring process, we use AI-powered tools to assist in the initial screening of applications. These tools help us identify qualifications and prior work experiences that align with the requirements of the role. We may also use AI assistant video tools during interviews to support note-taking and candidate evaluation. All AI-powered outputs are still subject to human oversight and decision-making at multiple stages of the process. By submitting your application, you acknowledge and consent to Pie utilizing these AI technologies to assist in our evaluation process.