Role Description With minimal oversight, the Senior Claims Adjuster I is responsible for the timely and accurate management of workers' compensation claims in California. This includes handling medical and indemnity benefits, addressing litigation and complex issues, and managing moderate to high exposure cases. Must work West Coast hours (M-F 8am-5pm PST) and have experience adjusting CALIFORNIA work comp claims. - Completes initial contacts to obtain necessary information, verify coverage, determine compensability and develop a plan of action. Completes and maintains claim data integrity. - Independently analyzes case facts to establish timely and accurate reserves using knowledge and experience with medical disabilities and related costs, as well as judgment of extent of disability. - Collaborates with Corporate Claims to proactively evaluate and mitigate high exposure losses. - Provides timely and appropriate customer service within established best practices. Maintains ongoing professional communications with all internal and external customers. - Accurately evaluates and pays benefits in compliance with statutory and company procedures and guidelines. Files appropriate state forms, as needed. - Proactively manages or coordinates medical treatment to continue to move the claim forward. Uses internal and external resources to contain costs and manage exposure. - Reviews and analyzes litigation and legal issues. Directs legal strategy and participates in preparation of the case for litigation. Collaborates with defense attorney to move claims to resolution. - Completes detailed settlement analysis and recommends appropriate settlement value, utilizing in-depth knowledge of appropriate workers’ compensation insurance principles and laws, subrogation recoveries, offsets and deductions, claim and disability duration, cost containment principles; including medical management practices and Social Security and Medicare application procedure as applicable. - Regularly reviews caseload and proactively takes action to guide claims efficiently and effectively to closure. Uses a high degree of independent judgment to render accurate decisions. - Mentors other team members and acts as a Subject Matter Expert for legal, jurisdiction and Company needs. - Other duties as assigned. Qualifications - 7 or more years of related claims experience including complex claim handling. Internal candidates with proven results may also qualify. - Superior communication and customer service skills and proficiency in an imaged environment. - Demonstrated knowledge of workers’ compensation laws and ability to adhere to statutes, regulations and company policies and practices, as well as related claim management procedures/protocols. - Self-motivated with the ability to work independently with minimal direction. The ability to multi-task and prioritize, adhere to deadlines and complete assignments accordingly. - Excellent analytical, problem solving and decision-making skills. - Equivalent combinations of education and experience may be considered. Requirements - Certification: WCCP, AIC, ARM, CPCU or other insurance designation preferred. - Education: Bachelor’s degree or equivalent business experience preferred. Benefits - Salary Range: $60,000-105,000 and a comprehensive benefits package. Company Description As a dynamic, fast-growing provider of workers' compensation insurance and services, we are seeking a goal-oriented individual willing to put their ideas to work! We offer a positive, challenging work environment, combined with an opportunity to build your career as you help us grow our business, in innovative and imaginative ways that are uniquely EMPLOYERS! - Headquartered in Nevada, EMPLOYERS attributes its long-standing success to its most valuable resource, our employees across the United States. - EMPLOYERS is known for the quality service and expertise we provide to our clients, and the exemplary work environment we provide for our employees. - We live and breathe our core values: Integrity, Customer Focus, Collaboration, Initiative, Accountability, Innovation, and Personal Fulfillment. - At EMPLOYERS, you’ll discover an energetic environment that inspires top achievement.

Role Description Our insurance carrier client is currently seeking a skilled and experienced Personal Auto Insurance Claims Adjuster to join their Claims Department. This will be a Remote position. As a Personal Auto Insurance Claims Adjuster, you will be responsible for investigating, evaluating, and settling personal auto insurance claims. You will work closely with policyholders, third-party claimants, and internal teams to assess liability, determine coverage, and negotiate settlements in accordance with company policies and regulatory requirements. Key Responsibilities: - Conduct thorough investigations to determine coverage, liability, and damages related to personal auto insurance claims. - Gather and analyze relevant information, including accident reports, witness statements, and vehicle inspections. - Evaluate vehicle damage and injuries to determine the extent of damages and the appropriate settlement amount. - Collaborate with repair shops, medical professionals, and other experts to assess damages accurately. - Interpret insurance policies to determine coverage and liability. - Communicate coverage decisions clearly and effectively to policyholders and claimants. Qualifications - Bachelor's degree in a related field or equivalent work experience. - 5+ years of experience as a Personal Auto Insurance Claims Adjuster. - Strong knowledge of auto insurance policies, coverage, and regulations. - Excellent communication and negotiation skills. - Detail-oriented with strong analytical and problem-solving abilities. Benefits - Compensation: $60,000 - $85,000/year - Comprehensive health, dental, and vision insurance. - Annual bonus between 5% - 10% based on company and personal performance. - 20 days of PTO. - 100% Company paid medical benefits to employee AND family. - 401k company matches 100% up to the first 3%. Company Description

• Analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities. • Work directly with claims administrators on behalf of ASO clients to secure claim adjustments, recoveries, and repricing. • Perform detailed audits of hospital and facility claims, including itemized bills, UB-04 claim forms, medical records, and remittance advices, to validate billing accuracy. • Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other irregularities that affect reimbursement. • Review high-cost and catastrophic claims (typically $100K+) to identify overpayments, contract misapplication, and opportunities for negotiated adjustments. • Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines to determine appropriate reimbursement. • Understand and apply stop loss (specific and aggregate) provisions, laser terms, and reporting requirements as they relate to claim adjustments and client financial exposure. • Serve as the subject matter expert and advocate on behalf of ASO clients in disputes with claims administrators (TPAs) and carriers regarding claim payment accuracy. • Prepare clear, well-documented findings packages (clinical, contractual, and coding rationale) to support requested claim adjustments and appeals.

Role Description Determine covered medical insurance benefits in accordance with the provisions of the plan document. Document medical claims processes by completing forms, reports, logs and records. Resolve medical claims by approving or denying, calculating benefit due and initiating payment or denial. Ensure legal compliance by following company policies, procedures, guidelines, as well as federal insurance regulations. - Account maintenance: Updating registration, authorization issues, identifying charge correction, processing adjustments as needed and denial follow up according to payer rules and departmental policies. - Use electronic billing system appropriately to follow up on outstanding denied claims and all no response claims. - Correct claims in electronic billing system for missing or invalid insurance or patient information according to procedures, and place account on hold if unable to resolve. - Follow up on denied or no response claims by calling third party payers or using payer websites. - Gather information from patients or other areas to resolve outstanding denied or no response claims. - Research accounts to take appropriate action necessary to resolve. - Keep management aware of issues and trends to enhance operations and escalate slow-pay issues to managerial level when necessary. - Use payer websites to stay current on payer rules and changes to include reading newsletters and communicating payer/claim issues and trends. - Maintain 95% quality standards on account follow and activity. - Maintain productivity standard as set forth by management team. - Other duties as assigned. Qualifications - Education: High School Degree or Equivalent - Work Experience: 0-6 months Benefits - Health, dental, vision, and life insurance - Employer Sponsored Retirement Plan - Paid time off and extended sick leave - Paid Parental Leave - Disability insurance plan options - Continuous professional and clinical training - Competitive pay - Annual Merit Increase - Wellbeing resources - Tuition Reimbursement - Employee perks and discounts - Employee referral program - Flexible schedule options - Certification incentive program