Senior Claims Adjuster - Remote CA, Complex Claims

EMC Insurance Companies; United States; Remote; USD 78,000 - 120,000; Full time

Job summary

EMC Insurance Companies in the United States seeks a seasoned workers’ compensation claims adjuster to take ownership of moderately to highly complex claims, drive investigations, set reserves, and shape strategies from start to resolution. You will initiate timely communications, review medical records, negotiate settlements, and mentor teammates while ensuring compliance with regulations.

The role is eligible to work from home anywhere in California.

Qualifications

• Bachelor’s degree or equivalent experience required.
• Five years of claims adjusting or related experience.
• Experience with a third party administrator (TPA) preferred.
• CPCU coursework preferred or designation beneficial.
• Workers’ compensation experience in CA preferred.

Responsibilities

• Analyze coverage to confirm losses are covered under client policies.
• Initiate contact within 24 hours with all relevant parties.
• Conduct thorough investigations including fact-finding and recorded statements.
• Develop and execute action plans to resolve claims efficiently.
• Perform reserve analysis and set/maintain reserves per client guidelines.
• Review medical records and bills to assess injury, compensability, treatment, and accuracy.
• Identify risk factors and route claims for specialized handling (SIU, subrogation, medical review).
• Identify, investigate, and pursue subrogation opportunities.
• Escalate complex claims and mentor team as needed.
• Prepare jurisdictional filings for workers’ compensation claims.
• Evaluate coverage, liability and claim value; respond to stakeholder inquiries.
• Negotiate settlements and manage payments within authority limits; support higher-value settlements.
• Maintain diaries and action plans, provide updates, and coordinate resources.

Skills

Analytical skills

Investigative skills

Problem-solving

Communication skills

Claims systems knowledge

Education

Bachelor's degree or equivalent

CPCU coursework preferred

Tools

Claims systems

Job description

EMC Insurance Companies in the United States seeks a seasoned workers’ compensation claims adjuster to take ownership of moderately to highly complex claims, drive investigations, set reserves, and shape strategies from start to resolution. You will initiate timely communications, review medical records, negotiate settlements, and mentor teammates while ensuring compliance with regulations.

The role is eligible to work from home anywhere in California.