• Manage lost time and medical only Workers' Compensation claims. • Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims. • Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines. • Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision. • Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed. • Utilize proactive reserving behaviors to ensure adequate case reserves. • Consults with assigned claim director, return to work specialists, nurse case managers, and internal/external medical professionals. • Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs.

Pie's mission is to empower small businesses to thrive by making commercial insurance affordable and as easy as pie. We leverage technology to transform how small businesses buy and experience commercial insurance. Like our small business customers, we are a diverse team of builders, dreamers, and entrepreneurs who are driven by core values and operating principles that guide every decision we make. The Senior Claims Adjuster will play a critical role in delivering quality claim file management and an industry-leading customer claims experience., This will be completed by adhering to Pie’s Claims Best Practices and complying with regulatory and statutory requirements. 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.. How You’ll Do ItClaims Technical Management: - Independently handle all aspects of the workers’ compensation claims from set-up to closure. - Evaluate and handle high dollar, high exposure, complex claims. - Conduct timely 3-point contact investigation, with focus on continued investigation as facts of the case change. - Mitigate the complex exposure while achieving the best outcome. - 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. 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. - Assist as necessary in providing claim status to agents and insureds, coverage verification and loss run reports, etc. - Provide excellent customer service to internal and external customers and business partners. - 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. The Right Stuff - High School Diploma or equivalent is required. - Bachelor's Degree or equivalent experience with some college coursework is preferred. - Minimum of 5-years workers’ compensation claim adjusting experience is required (carrier background, preferred). - Claims experience handling California WC claims is required. - Ability to evaluate and identify high dollar, high exposure, complex claims. - Requires active licensing in applicable states 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. - 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. Base Compensation Range $95,000—$120,000 USD Compensation & 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 - Our core values are more than just a poster on the wall; they’re tangibly reflected in our work Making every part of working with us "Easy as Pie" - including our offer process. When we find someone we'd like as a Pie-oneer (a member of our team), we move quickly to put together a fair offer based on your skills, experience, location, and compensation expectations. Each year Pie reviews company performance and may grant discretionary bonuses to eligible team members. 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 InformationPie 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. Pie Insurance participates in the E-Verify program. Please click here, here and here for more information. Pie Insurance is committed to protecting your personal data. Please review our Privacy Policy. 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. Pie Named to 2025 America's Best Startup Employers Pie Insurance 2025 State of Workplace Safety Report #LI-REMOTE #BI-REMOTE

Role Description Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims. - Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse. - Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud. - Consults with benefit integrity investigation experts and pharmacists for advice and clarification. - Completes case summaries and provides results to investigators to support the investigative process. - Provides case specific or plan specific data entry and reporting. - Participates in internal and external focus groups, as required. - Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations. - Testifies at various legal proceedings, as necessary. - Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions. Qualifications - Minimum Bachelor's Degree required (can be substituted for experience). - 2 - 4 years of experience required; 5 - 7 years preferred. - Medical Review or Utilization Management experience preferred. - Medicare/Medicaid experience preferred. Requirements - Current, active and non-restricted RN licensure required. - Coding certification preferred. Benefits - Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities. - Qlarant is a drug-free workplace. All offers of employment are contingent upon successful completion of pre-employment background and drug screens.

Role Description As an Auto Claims Specialist at Revecore, you will make high-volume, outbound calls to investigate, bill, and maximize payments on medical claims to insurance companies, on behalf of our clients (hospitals and medical providers). - Investigate and research details of an auto accident to determine the payer. - Make a high volume of outbound calls to patients, insurance company representatives, and attorneys. - Submit bills and proper documentation to the insurance company, ensuring maximized payments to our clients. - Determine follow-up steps and resubmit bills for additional payment if bills aren't paid correctly. - Contribute to your team with various denial reports, audits, and overall support. Qualifications - Working knowledge of Microsoft Office (Word, Excel, Outlook). - Technical proficiency to work on multiple computer screens and software applications simultaneously. - Ability to maintain strong performance in a fast-paced, high outbound call center environment with productivity metrics. - Organizational skills while multi-tasking. - Critical thinking and problem-solving skills to find effective and efficient solutions. - Clear communication skills, both verbally and in writing. - Experience with Coordination of Benefits and a general understanding of insurance billing (a plus, but not required). Requirements - A private, distraction-free environment to work from in your home. - On-Camera Presence: Being on camera is essential for building trust, supporting collaboration, and strengthening team connections. - A secure internet connection. - Home internet with speeds >20 Mbps for downloads and >10 Mbps for uploads. - Workspace must accommodate all workstation equipment (laptop, monitor, keyboard, mouse, docking station, and headset). - Employment is contingent upon eligibility to work in the U.S., employment history verification, and a background check. Benefits - Paid training and incentive plans. - Medical, dental, vision, and life insurance benefits available on day 1. - Excellent work/life balance. - Employee Resource Groups build community and foster a culture of belonging and inclusion. - 401(k) contributions matched. - Career growth opportunities. - 12 paid holidays and generous paid time off.