The Claims Adjuster will play a critical role in ensuring quality claim file management, service level agreements are met, and regulatory requirements are satisfied all while helping to create and provide an industry leading customer claims experience. This will be completed by working with internal and external partners to drive performance, identify trends, and report findings to internal Pie Leaders. The Claims Adjuster role does not currently involve active claim handling. However, this position will require direct claim handling activities as our program grows. 

How You’ll Do It

• Claims Technical Management

  • Independently handle all aspects of the workers’ compensation claims from set-up to closure.
  • Conduct timely 3-point contact investigation, with focus on continued investigation as facts of the case change.
  • Mitigate claim exposure while achieving the best outcome.
  • Determine timely and accurate compensability decision within statutory requirements.
  • Set and adjust timely/accurate reserves within authority limits to ensure reserving activities are consistent with the case facts and company best practices.
  • Timely administration of statutory medical and indemnity benefits throughout the life of the claim.
  • Comply with all applicable statutory guidelines, rules, and regulations.
  • Control legal activity with defense counsel through the litigation process while managing legal fees and costs.
  • Prioritize early resolution opportunities, evaluate claim exposure and negotiate settlement.

• Claims Quality Assurance (QA)

  • Responsible for ensuring claims are handled in accordance with established guidelines and service instructions. 
  • Ensures timely completion of file reviews, calibration sessions and analysis reports.
  • Identify claim handling trends by applying industry knowledge of the claims process, policies & procedures, and regulatory environment.
  • Meet regularly with Claims Leadership to provide QA results and recommendations for opportunities for improvement.

• Claims Technical Oversight

  • Provide technical direction on claim decisions and resolution in partnership with our external Third Party Administrator (TPA) partner within the assigned authority level.
  • Assist as necessary in providing claim status to agents and insureds, coverage verification and loss run reports, etc.

• Claims Customer Service

  • Serve as a point of contact for our partner agents and customers to provide general claim guidance and help set claim process expectations.
  • Provide excellent customer service to internal and external customers and business partners. 
  • Participate in interactions with TPA adjusters and claims partners to drive optimized claims outcomes and top-notch claims experience.
  • Advocate to ensure that Pie has a leading claims customer experience.
  • Work to continuously improve our claims operations and look at opportunities and gaps in claim service, handling SOPs, protocols and processes. 

• Analytics 

  • Support Pie’s efforts to gather data to better inform our decisions, reporting and overall performance. 
  • Use data to generate reports to inform on claims program trends and performance to goals.
  • Work collaboratively with Pie leaders and teams in Product, Underwriting, Compliance, Sales, and Customer Success to analyze data and metrics.

The Right Stuff

• High School Diploma or equivalent is required.
• Bachelor’s Degree or equivalent experience with some college coursework is preferred.
• Minimum of 2-years workers’ compensation claims experience is required.  
• Requires at least one Claims Adjuster License in one of the following states: CA, NY, IL, IN, MO, NE, WI, FL, GA (multiple states preferred)
• Strong communication (written and verbal) skills, to deliver more complex information effectively.
• Strong  problem solving skills to be able to manage complex tasks and work through to solutions with little guidance and direction.
• Awareness of your own tasks, and how it impacts the team and deliverables.
• Experience using G-Suite Tools, and collaboration tools like Slack is preferred.
• Developed knowledge of jurisdictional regulatory and statutory requirements and CMS/MSA requirements.
• Demonstrated knowledge and experience in claim adjudication, medical management and litigation management.
• Developing ability to analyze and take necessary action in multiple focus areas, based on several data points.
• Ability to use skills to overcome conflict and reach beneficial outcomes.
• Ability to make claim decisions to mitigate exposure while achieving the best outcome.

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