Senior Remote Claims Leader — Complex Workers’ Comp

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

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.