Senior Claims Adjuster (Workers' Compensation)

EMC Insurance; California (MO); Hybrid; USD 79,000 - 120,000; Full time

Benefits offered by this job

401(k) plan match

Pension plan

OneEMC bonus plan

Tuition reimbursement

Wellness initiatives

Job summary

EMC Insurance is seeking an experienced workers' compensation claims adjuster to take ownership of moderately to highly complex claims in California. You will drive investigations, evaluate coverage and liability, set reserves, and shape claim strategies from start to resolution, balancing analysis with decisive action.

Build relationships with clients and stakeholders while mentoring team members and ensuring regulatory compliance.

Qualifications

• Bachelor’s degree or equivalent relevant experience
• Five years of claims adjusting experience or related experience
• Prior experience with a third party administrator (TPA) preferred
• INS, AIC, SCLA, WCLA and CPCU coursework or designation preferred
• Workers' compensation claims adjusting experience within CA preferred

Responsibilities

• Analyzes coverage to confirm losses are covered under client policies
• Initiates contact within 24 hours with all relevant parties (clients, claimants, employees, medical providers)
• Conducts thorough investigations, including fact-finding and recorded statements
• Develops and executes action plans to resolve claims efficiently
• Performs reserve analysis and sets/maintains appropriate reserves per client guidelines
• Reviews medical records and bills to assess injury, compensability, treatment, and accuracy
• Identifies risk factors and routes claims for specialized handling (SIU, subrogation, medical review) with approval
• Identifies, investigates, and pursues subrogation opportunities, including review of official reports
• Escalates complex claims and collaborates with leadership as needed
• Prepares required jurisdictional filings for workers’ compensation claims
• Evaluates coverage, liability, and claim value; responds to stakeholder inquiries
• Negotiates settlements, participates in mediation, and manages payments within authority limits; recommends higher-value settlements
• Prepares and issues denial and settlement documentation; develops evaluation ranges and supports litigation, mediation, arbitration, and Medicare compliance
• Maintains diaries and action plans, provides timely responses and claim updates, conducts client consultations, coordinates vendor resources, manages reporting (including excess carriers), stays current on regulations, maintains licenses/CEUs, and supports training of team members

Skills

Analytical skills

Investigation

Negotiation

Communication

Education

Bachelor's degree or equivalent

5 years claims adjusting experience

CA workers' compensation experience

INS, AIC, SCLA, WCLA and CPCU coursework or designation preferred

Tools

Claims systems

Job description

At EMC, we’re all about working together to make an impact. As part of our team, you’ll have the opportunity to grow, contribute, and gain experience that matters. We strive to be caring leaders, close partners, and responsive experts—always supporting each other to do our best work. Join us, and let’s improve lives together.

This position is eligible to work from home anywhere in the state of California

In this role, you’ll have the opportunity to take ownership of moderately to highly complex workers' compensation claims and make a direct impact on outcomes for clients and claimants. You’ll drive investigations, evaluate coverage and liability, and shape claim strategies from start to resolution—balancing thoughtful analysis with decisive action. Your expertise will be key in setting reserves, negotiating fair settlements, and identifying risk and recovery opportunities. Along the way, you’ll build strong relationships with clients and stakeholders, ensure compliance with evolving regulations, and play a meaningful role in mentoring others and elevating team performance.

Essential Functions

• Analyzes coverage to confirm losses are covered under client policies
• Initiates contact within 24 hours with all relevant parties (clients, claimants, employees, medical providers)
• Conducts thorough investigations, including fact-finding and recorded statements
• Develops and executes action plans to resolve claims efficiently
• Performs reserve analysis and sets/maintains appropriate reserves per client guidelines
• Reviews medical records and bills to assess injury, compensability, treatment, and accuracy
• Identifies risk factors and routes claims for specialized handling (SIU, subrogation, medical review) with approval
• Identifies, investigates, and pursues subrogation opportunities, including review of official reports
• Escalates complex claims and collaborates with leadership as needed
• Prepares required jurisdictional filings for workers’ compensation claims
• Evaluates coverage, liability, and claim value; responds to stakeholder inquiries
• Negotiates settlements, participates in mediation, and manages payments within authority limits; recommends higher-value settlements
• Prepares and issues denial and settlement documentation; develops evaluation ranges and supports litigation, mediation, arbitration, and Medicare compliance
• Maintains diaries and action plans, provides timely responses and claim updates, conducts client consultations, coordinates vendor resources, manages reporting (including excess carriers), stays current on regulations, maintains licenses/CEUs, and supports training of team members

Education & Experience

• Bachelor’s degree or equivalent relevant experience
• Five years of claims adjusting experience or related experience
• Prior experience with a third party administrator (TPA) preferred
• INS, AIC, SCLA, WCLA and CPCU coursework or designation preferred
• Workers' compensation claims adjusting experience within the following jurisdictions preferred: CA

Knowledge, Skills, & Abilities

• Excellent knowledge of the theory and practice of the claim function
• Excellent analytical, investigative and problem-solving abilities with respect to liability and coverage
• Thorough knowledge of insurance contracts, medical terminology and legal aspects of court procedures affecting legal liability for all lines of insurance.
• Strong computer skills, including claims systems
• Strong organizational, written, and verbal communication skills, including documentation
• Strong ability to advise, partner, and effectively consult with diverse internal and external stakeholders
• Occasional travel required; a valid driver’s license with an acceptable motor vehicle report per company standards

The hiring salary range for this position will vary based on geographic location, falling within either of the following: $78,726 - $108,771 or $87,008 - $119,646. A hiring range represents a subset of the full salary range. The actual salary will depend on several factors, including relevant education, skills, and experience of an applicant, geographic location, and business needs.

For information relating to the benefits EMC Team Members receive as part of a comprehensive rewards package, please visit www.emcins.com/careers.

Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws.

All of our locations are tobacco free including in company vehicles.

Why should you choose to apply for a position at EMC?

• More than 105 years of financial strength and stability
• Named a five-star insurance carrier by Insurance Business America
• Two-time recipient of the Best Practices Award of Excellence from the Independent Agents & Brokers of America
• Multiple locations recognized as Top Workplaces based solely on team member feedback
• Corporate culture that engages and empowers team members to achieve their best
• Outstanding benefits with life, medical, dental, vision and prescription drug coverage
• Competitive paid time off plan and a full day of volunteer time off annually
• Financial incentives, including a 401(k) plan match, pension plan, OneEMC bonus plan and recognition and anniversary awards
• Professional development and growth opportunities, including tuition reimbursement
• Wellness initiatives to improve team member well-being and reduce health insurance costs
• Flexibility to dress for your day and opportunities for alternative work arrangements
• EMC complies with labor law requirements.
• View the federal and e-verify labor law posters.
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