Complex Claims Adjuster, Workers Compensation (California)

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.  

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.

• 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.
• Requires active  licensing in applicable states. 
• Experience in the following states preferred: CA primary, additional experience in AZ, UT is a plus. 
• Advanced communication (written and verbal) skills, to deliver more complex information effectively.
• Advanced 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.
• Advanced knowledge of jurisdictional regulatory and statutory requirements and CMS/MSA requirements.
• Advanced knowledge and experience in claim adjudication, medical, and litigation management.
• Advanced ability to analyze and take necessary action in multiple focus areas based on several data points.
• Ability to make claim decisions to mitigate exposure while achieving the best outcome.
• Ability to use skills to overcome conflict and reach beneficial outcomes.
• Ability to mentor junior adjusters.

The use of AI in Application Review: To support a fair, efficient, and consistent hiring process, we use AI-powered tools to assist in the initial screening of applications. These tools help us identify qualifications and prior work experiences that align with the requirements of the role. We may also use AI assistant video tools during interviews to support note-taking and candidate evaluation. All AI-powered outputs are still subject to human oversight and decision-making at multiple stages of the process. By submitting your application, you acknowledge and consent to Pie utilizing these AI technologies to assist in our evaluation process.