• Works closely with veterinary hospitals, and policyholders to evaluate and review a pet’s medical history to determine a baseline of health. • Investigates and processes assigned insurance claims, verifies coverage, and compensation amounts, per insurance policy. • Updates Explanation of Benefits (EOB), pays and closes claim. • May order medical records from providers. • May communicate with clients and providers during treatment. • Performs other duties and responsibilities as assigned.

• Monitor BlueWeb for Association updates and analyze release notes to determine claim, pricing, and training impacts. • Track provider terminations and communicate impacts; coordinate continuity-of-care and disruption analysis. • Serve as SME on BlueCard/ITS claims processing rules and operational program requirements. Coach team members accordingly on guidelines and changes. • Coordinate Association projects and rule interpretation with Regence and InterPlan Executives. • Act as key escalation point for Plan-to-Plan issues. • Cascade InterPlan communications to internal teams. • Oversee complex ITS/BlueCard workflows; lead system and pricing enhancement projects. • Test and validate system updates; refine ITS/BlueCard policies and procedures. • Conduct root-cause analysis on recurring issues and implement improvements. • Monitor and communicate InterPlan performance metrics (IPP). • Track quality and productivity metrics; lead improvement initiatives. • Oversee daily ITS claims workflows and ensure timely, accurate adjudication across all claim types. • Serve as the primary escalation point for the most complex, sensitive, or high-impact ITS/BlueCard claim issues. • Partner with leadership to refine ITS policies, update procedures, and support operational strategy. • Act as a liaison with BCBS host/home plans and external partners for escalated claim issues.

• partners with professional staff on pre-screening review by applying guidance • makes appropriate decision which may include interpretation of provider information or data • focuses on methods, tactics and processes for completing administrative tasks/projects • regularly exercises discretion and judgment in prioritizing requests and interpreting procedures

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 Claims Adjuster will play a vital 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. - 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 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. - 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. - 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. 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. - Claims experience working in the following states: Florida, Georgia, North Carolina, South Carolina, and Tennessee. - 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. - 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. 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 $70,000—$90,000 USD Compensation & Benefits - Competitive cash compensation - 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