Senior Workers' Comp Claims Adjuster — Remote

EMC Insurance; United States; Remote; USD 79,000 - 120,000; Full time

Job summary

EMC Insurance in the United States is seeking a claims professional to own moderately to highly complex workers’ compensation claims, driving investigations, evaluating coverage and liability, and shaping claim strategies from start to resolution. You will set reserves, negotiate settlements, and identify risk and recovery opportunities while mentoring teammates and collaborating with clients and stakeholders.

The role emphasizes regulatory compliance and strong communication.

Qualifications

• Strong analytical, investigative and problem-solving abilities with respect to liability and coverage.
• Thorough knowledge of insurance contracts, medical terminology and legal aspects affecting liability.
• Excellent written and verbal communication, documentation, and stakeholder consulting.
• Experience with a third party administrator (TPA) 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).
• 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; 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, and maintains licenses/CEUs.

Skills

Analytical abilities

Investigative skills

Communication skills

Negotiation skills

Project management

Education

Bachelor’s degree or equivalent experience

CPCU coursework or designation

INS/AIC/SCLA/WCLA coursework

Tools

Claims systems

Job description

EMC Insurance in the United States is seeking a claims professional to own moderately to highly complex workers’ compensation claims, driving investigations, evaluating coverage and liability, and shaping claim strategies from start to resolution. You will set reserves, negotiate settlements, and identify risk and recovery opportunities while mentoring teammates and collaborating with clients and stakeholders.

The role emphasizes regulatory compliance and strong communication.