[Hiring] Complex Claims Adjuster @Pie Insurance

Role Description

The Complex Claims Adjuster will play a critical role in delivering quality claim file management and an industry-leading customer claims experience by providing hands-on adjudication of catastrophic and large loss claims. This will be completed by adhering to Pie’s Claims Best Practices, complying with regulatory and statutory requirements, and applying advanced knowledge and experience with complex negotiation strategies, structured settlements, Medicare Set-Aside requirements, and overall risk evaluation and mitigation. This role will work with internal and external partners to deliver best in class performance, identify and pursue claim mitigation opportunities, and deliver favorable claim outcomes for Pie’s customers.

Additionally, the Complex Claims Adjuster will collaborate with the Complex Claims Practices Consultant and Claims leadership to continually seek out ways in which to improve claims processes and protocols.

How You’ll Do It

• Claims Technical Management:
  • Independently handle all aspects of catastrophic and large loss 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.
  • Determine timely and accurate compensability decisions 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.
  • Ability to present claims to senior management, internal and external stakeholders.
  • 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.
  • Mitigate the complex exposure while achieving the best outcome.
• 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 claim status to agents and insureds, coverage verification and loss run reports, etc. as necessary.
  • Provide excellent customer service to internal/external customers and business partners.
  • Work to continuously improve our claims operations and address opportunities and gaps in claim service, handling SOPs, protocols, and processes.
• Claims Resolution Management:
  • Direct a proactive litigation strategy to increase settlement opportunities.
  • Assess claims for settlement value using rated ages, present value, Medicare set asides, medical cost projections, and structured settlements. Obtain settlement authority as required.
  • Obtain annuity and structured settlement quotes.
  • Attend virtual and in-person mediations, informal settlement conferences, and trials to represent Pie's interests.
• Collaboration & Innovation:
  • Participate in Claims Roundtable meetings. Develop a collaborative plan of action for aggressive claims handling.
  • Create Claims Status Reports and establish timely, accurate reserves.
  • Present large loss updates to internal and external partners.
  • Collaborate with our Complex Claims Practices Consultant and Claims Leadership to continuously improve our claims operations and look at opportunities and gaps in claim service, handling SOPs, protocols, and processes.

Qualifications

• High School Diploma or equivalent is required.
• Bachelor's Degree or equivalent experience with some college coursework is preferred.
• Minimum of 7 years workers’ compensation claim adjusting experience is required (carrier background preferred).
• 2+ years of catastrophic claim handling experience.
• Ability to evaluate and identify high dollar, high exposure, complex claims.
• Strong claims handling experience within the Southeast region preferred, with expertise in Florida, Georgia, and/or North Carolina.
• Requires active licensing in applicable states.
• Advanced communication (written and verbal) skills, to deliver more complex information effectively.
• Advanced problem-solving skills to manage complex tasks and work through to solutions with little guidance and direction.
• Experience using G-Suite Tools and collaboration tools like Slack is preferred.
• Advanced knowledge of jurisdictional regulatory and statutory requirements and CMS/MSA requirements.
• Advanced knowledge and experience in claim adjudication, medical, and litigation management.
• Ability to mentor junior adjusters.

Requirements

• Ability to make claim decisions to mitigate exposure while achieving the best outcome.
• Ability to use skills to overcome conflict and reach beneficial outcomes.

Benefits

• Competitive cash compensation.
• A piece of the pie (in the form of equity).
• Comprehensive health plans.
• Generous PTO.
• Future focused 401k match.
• Generous parental and caregiver leave.
• Discretionary bonuses to eligible team members based on company performance.

Location Information

Unless otherwise specified, this role is remote. Remote team members must live and work in the United States (territories excluded) and have access to reliable, high-speed internet.

Additional Information

Pie Insurance is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristic.

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Safety First: Pie Insurance is committed to your security during the recruitment process. We will never ask you for credit card information or ask you to purchase any equipment during our interview or onboarding process.