Senior Claims Adjuster

MEM; United States; On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Health plans

Life & disability benefits

Wellness program

401k match

Job summary

MEM Insurance seeks a Senior Claims Representative to manage high-exposure workers’ compensation claims and lead investigations into coverage and fraud. You will mentor junior adjusters, drive process improvements, and collaborate across departments to deliver exceptional service and regulatory compliance.

You will oversee medical case management for catastrophic injuries, review large bills, and participate in settlement and subrogation activities while supporting strategic risk management and

Qualifications

• Bachelor’s degree in business or related field preferred or equivalent industry experience.
• 7–10 years of claims handling experience with high exposure to workers’ compensation.
• AIC, AIM, or CPCU designation preferred or ability to obtain.
• Valid driver’s license required.

Responsibilities

• Manage highly complex workers’ compensation claims with significant financial exposure.
• Lead investigations into coverage, fraud, and statutory interpretations.
• Oversee medical case management for catastrophic injuries and lifetime care needs.
• Review and authorize large or complex medical bills, negotiating adjustments.

Skills

Claims handling

Investigation

Negotiation

Leadership/mentoring

Regulatory compliance

Education

Bachelor’s degree in business or related field

AIC/AIM/CPCU designation preferred

Job description

Are you a seasoned claims professional with a passion for navigating complex cases? MEM Insurance is seeking a Senior Claims Representative to join our Claims team. In this pivotal role, you’ll manage high-exposure workers’ compensation claims, lead investigations into coverage and fraud, and collaborate across departments to drive strategic outcomes. You’ll be a key decision‑maker, a mentor to junior adjusters, and a champion of process improvement—all while ensuring exceptional service and regulatory compliance.

Essential Duties and Responsibilities

• Manage highly complex claims involving significant financial exposure, legal intricacies, and extended life cycles.
• Conduct advanced investigations into coverage and compensability, including nuanced statutory interpretations.
• Oversee medical case management for catastrophic injuries and lifetime care needs.
• Review and authorize large or complex medical bills, negotiating adjustments to control costs.

Return-to-Work Management

• Develop comprehensive RTW strategies in collaboration with policyholders, legal counsel, and vocational consultants.
• Ensure precision in benefit calculations for high‑exposure claims, addressing tax and compliance risks.
• Strategically deploy investigative efforts aligned with broader claims strategy.
• Lead investigations into complex fraud cases and collaborate with the Special Investigations Unit.
• Conduct subrogation analysis and negotiate with third‑party insurers or attorneys for maximum recovery.

Settlements & Negotiation

• Partner with legal teams to negotiate complex settlements and manage litigation processes.
• Oversee Medicare compliance initiatives, including Medicare Set‑Asides and CMS engagement.
• Identify opportunities for structured settlements and lead negotiations.

Reporting

• Produce strategic reports on high‑profile claims to guide management decisions.
• Maintain system data integrity and prepare claims for Corporate Plan of Action meetings.
• Lead cross‑departmental efforts to improve claims handling and risk management.
• Resolve escalated customer service issues and support high‑value accounts.
• Participate in workflow improvement initiatives and committees.
• Mentor and coach junior and intermediate adjusters.
• Review escalated claims and provide actionable feedback.
• Support workforce development and succession planning.

Qualifications

• Bachelor’s degree in business or related field preferred, or equivalent industry experience.
• 7–10 years of claims handling experience, with high exposure to Workers’ Compensation.
• Associate in Claims (AIC), AIM, or CPCU designation preferred or ability to obtain.
• Valid driver’s license required.

Company Culture And Values

At MEM Insurance, we foster a culture of integrity, collaboration, and innovation. Our team thrives on solving challenges together, supporting one another, and making a meaningful impact in the lives of our policyholders and injured workers.

MEM Insurance is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We believe that varied perspectives drive innovation and strengthen our ability to serve our customers and communities.

Total Rewards Overview

• Health Plans: Medical, Dental, and Vision Includes fertility benefits, fully paid preventative care, and adult orthodontia.
• Employer‑Paid Life and Disability Benefits: Life Insurance (3x base salary), AD&D, Short and Long‑term Disability.
• Wellness and Recognition Program: Employer‑paid incentives for employees and spouses.
• Flexible Spending Account and Dependent Care options
• Time Away from Work: Generous PTO, 11 Holidays + 4 Early Releases, 16 Hours Volunteer Time Off, 20 Days Paid Parental Leave, Marriage, Bereavement, and Jury Duty leave.
• Employee Assistance Programs
• 401k Retirement Plan: Employer match and profit sharing.
• Adoption Assistance and Tuition Assistance