Senior Workers Compensation Claims Adjuster

Lodestar Claims & Risk Services; Roseville (CA); A distancia; USD 80.000 - 110.000; Jornada completa

Descripción de la vacante

Lodestar Claims & Risk Services is seeking a Senior Claims Specialist to independently investigate and resolve high-complexity workers' compensation claims. You will assess coverage, eligibility, subrogation, and reserves while coordinating with specialists and clients.

Work includes collaboration with Lodestar nurses to implement return-to-work strategies, manage vendors, and ensure compliance with jurisdictional requirements. Advanced communication and analytical skills are essential.

Formación

• Bachelor's degree or four+ years of equivalent work experience in insurance required.
• 3–5 years' experience handling lost time workers' compensation claims; CA jurisdiction experience required.
• SIP certification strongly preferred; active license within 90 days in mandating states.

Responsabilidades

• Investigate claims with minimal supervision, including complex cases.
• Determine coverage, compensability, subrogation potential, and second injury fund where applicable.
• Notify supervisor of potentially suspect claims and escalate as needed.
• Ensure timely denial or payment of benefits per jurisdictional requirements.
• Establish and adjust reserves with rationale throughout the claim life.
• Negotiate settlements with client approval.
• Develop and implement action plans for case resolution, including medical and disability management.
• Collaborate with Lodestar nurses to create return-to-work strategies.
• Select and manage service vendors balancing expense and loss outcomes.
• Maintain knowledge of state-specific laws and relevant case law for serviced states.
• Demonstrate best claim practices with timely, accurate execution.
• Communicate effectively with internal and external parties on claims and accounts.

Conocimientos

Communication

Organization

Critical thinking

Customer service

Educación

Bachelor's degree or 4+ years of equivalent work experience

Herramientas

MS Office

Descripción del empleo

#4940

Location

PMA Remote-PMAR

Position

Sr Claims Spec

External Description

As a member of our claims team, utilize your knowledge of Workers Compensation to independently investigate, evaluate and resolve assigned claims of a more complex nature in order to achieve appropriate outcomes. In this position you will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statutes, policy provisions, and company guidelines.

Responsibilities

• Promptly investigate all assigned claims with minimal supervision, including those of a more complex nature
• Determine coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)
• Alert Supervisor and Special Investigations Unit to potentially suspect claims
• Ensure timely denial or payment of benefits in accordance with jurisdictional requirements
• Establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure
• Negotiate claims settlements with client approval
• Establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
• Work collaboratively with Lodestar nurse professionals to develop and execute return to work strategies
• Select and manage service vendors to achieve appropriate balance between allocated expense and loss outcome
• Maintain a working knowledge of jurisdictional requirements and applicable case law for each state serviced
• Demonstrate technical proficiency through timely, consistent execution of best claim practices
• Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
• Provide a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
• Authorize treatment based on the practiced protocols established by statute or the Lodestar Managed Care department
• Assist Lodestar clients by suggesting panel provider information in accordance with applicable state statutes.
• Demonstrate commitment to Company’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

Requirements

• Bachelor's degree, or four or more years of equivalent work experience required in an insurance related industry required
• At least 3-5 years' experience handling lost time workers compensation claims required; past experience with CA jurisdiction is required
• SIP certification strongly preferred
• Active license required or ability to obtain license within 90 days of employment in mandated states.
• Familiarity with medical terminology and/or Workers' Compensation
• Strong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneously
• Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
• Strong verbal, written communication skills and customer service skills
• Computer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint.
• Ability to travel for business purposes, approximately less than 10%.

This Company is an Equal Opportunity Employer, and does not discriminate on the basis of race, gender, ethnicity, religion, national origin, age, disability, veteran status, or on any other basis prohibited by law. Information on race, gender and national origin will only be used for statistical and recordkeeping purposes, and will not be used in making any employment decisions. All information provided will be kept separate from your expression of interest. Providing this information is strictly voluntary, and you will not be subjected to any adverse action or treatment if you choose not to provide this information. If you do not choose to answer these questions, we ask that you select "Decline to Identify" for each question. Thank you for your voluntary cooperation.

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