Senior Claims Examiner

MEM; Missouri; On-site; USD 90,000 - 130,000; Full time

Benefits offered by this job

Health plans

401k with employer match

Generous PTO and holidays

Education assistance

Job summary

MEM Insurance is seeking a Senior Claims Representative to join our Claims team. You will manage high-exposure workers’ compensation claims, lead investigations into coverage and fraud, and mentor junior adjusters while driving process improvements.

You will collaborate across departments to ensure regulatory compliance, deliver exceptional service, and support strategic outcomes for policyholders and injured workers.

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.

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.
• 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.
• 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.
• 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.

Education

Bachelor’s degree in business or related field

Associate in Claims (AIC), AIM, or CPCU designation

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.

At MEM Insurance, we don’t just protect our customers—we empower our employees. 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.

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 are committed to our vision, mission, and values. We foster a culture of collaboration, integrity, and innovation. Our team is passionate about delivering exceptional service to our customers while supporting each other’s growth and success. We believe in accountability, continuous learning, and creating an environment where employees feel valued and empowered.

Connection and Belonging

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

Notice Regarding Use of Artificial Intelligence

MEM may use artificial intelligence (AI) tools to more efficiently facilitate and assist in decisions involving recruitment, hiring, promotion, renewal of employment, selection for training or apprenticeship, discharge, discipline, tenure, or the terms, privileges, or conditions of employment. Any such use of AI tools will comply with all applicable laws.