Medical Only Claims Adjuster New

Pie Insurance; Northern (KY); Hybrid; USD 60,000 - 75,000; Full time

Benefits offered by this job

Competitive cash compensation

Generous PTO

Future focused 401k match

Generous parental and caregiver leave

Job summary

Pie Insurance is seeking an experienced Medical Only Claims Adjuster to independently manage workers’ compensation medical-only claims from setup to closure.

You will investigate, manage treatments, and resolve claims while adhering to regulatory requirements. The role emphasizes excellent customer service and collaboration with agents and insureds in a remote US environment.

Qualifications

• High School Diploma or equivalent required or equivalent experience.
• Bachelor's degree or some college coursework preferred.
• Minimum 1 year of workers’ compensation claims experience as Medical Only Adjuster required.

Responsibilities

• Independently handle all aspects of workers’ compensation medical only claims from setup to closure.
• Conduct timely 2-point contact investigation focusing on medical management and claim closure.
• Mitigate claim exposure while achieving favorable outcomes.
• Determine timely, accurate compensability decisions per statutory requirements.
• Set and adjust reserves within authority limits per case facts.
• Administer statutory medical benefits throughout the life of the claim.
• Use Utilization Review where appropriate and timely pay medical bills.
• Comply with applicable guidelines, rules, and regulations.
• Identify claims meeting indemnity conversion criteria and elevate timely.
• Resolve medical treatment to close claims and manage lien resolutions.

Skills

Proficient communication

Attention to detail

Self-motivation

Education

High School Diploma or equivalent

Bachelor's Degree or equivalent

Tools

G-Suite

Slack

Job description

Pie's mission is to empower small businesses to thrive by making commercial insurance affordable and as easy as pie. We leverage technology to transform how small businesses buy and experience commercial insurance.

Like our small business customers, we are a diverse team of builders, dreamers, and entrepreneurs who are driven bycore values and operating principles that guide every decision we make.

The Medical Only Claims Adjuster will play a vital 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 medical only claims from set-up to closure.
• Conduct timely 2-point contact investigation, with focus on continued medical management, potential for lost time benefits, and claim closure as facts of the case change.
• Mitigate claim 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.
• Timely administration of statutory medical benefits throughout the life of the claim.
• Use Utilization Review where appropriate and pay medical bills within the allotted timeframes
• Comply with all applicable statutory guidelines, rules, and regulations.
• Proactively identify and timely elevate claims that meet indemnity claim conversion criteria
• Consistent and timely resolution of medical treatment to resolve and close claims
• Maintain a split inventory of Lien resolution claims, negotiating liens to appropriate resolution

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 1 year of workers’ compensation claims experience as a Medical Only Adjuster is required.
• Minimum 1 year of experience in California handling required.
• Additional experience in the following states preferred: Arizona and Utah
• Proficient communication (written and verbal) skills, to deliver information effectively.
• 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.
• Demonstrated knowledge and experience in claim adjudication and medical management.
• Developing ability to analyze and take necessary action in multiple focus areas, based on several data points.
• Ability to use skills to overcome conflict and reach beneficial outcomes.
• Ability to make claim decisions to mitigate exposure while achieving the best outcome.

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.

Base Compensation Range

$60,000 - $75,000 USD

• Competitive cash compensation
• Generous PTO
• Future focused 401k match
• Generous parental and caregiver leave
• Our core values are more than just a poster on the wall; they’re tangibly reflected in our work

Making every part of working with us "Easy as Pie" - including our offer process. When we find someone we'd like as a Pie-oneer (a member of our team), we move quickly to put together a fair offer based on your skills, experience, location, and compensation expectations.

Each year Pie reviews company performance and may grant discretionary bonuses to eligible team members.

Location Information

Unless otherwise specified, this role is remote. Remote team members must live and work in the United States (territories excluded) and have access to reliable, high-speed internet.

Additional Information

Pie Insurance is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristic.

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Safety First: Pie Insurance is committed to your security during the recruitment process. We will never ask you for credit card information or ask you to purchase any equipment during our interview or onboarding process.

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