Medical Only Claims Adjuster - Pie Insurance

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 that guide every decision we make.

The Medical Only Claims Adjuster plays 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 It

Claims Technical Management

• Independently handle all aspects of workers’ compensation medical-only claims from set-up to closure.
• Conduct timely 2-point contact investigations, focusing on continued medical management, potential lost time benefits, and claim closure as case facts change.
• Mitigate claim exposure while achieving the best outcome.
• Determine timely and accurate compensability decisions within statutory requirements.
• Set and adjust timely and accurate reserves within authority limits to ensure reserving activities are consistent with case facts and company best practices.
• Timely administration of statutory medical benefits throughout the life of the claim.
• Use Utilization Review where appropriate and pay medical bills within allotted timeframes.
• Comply with all applicable statutory guidelines, rules, and regulations.
• Proactively identify and timely escalate claims that meet indemnity claim conversion criteria.
• Consistent and timely resolution of medical treatment to resolve and close claims.
• Maintain a split inventory of Lien resolution claims, negotiating liens to appropriate resolution.

Claims Customer Service

• Serve as a point of contact for partner agents and customers to provide general claim guidance and set expectation.
• Assist as necessary in providing claim status to agents and insureds, coverage verification, loss run reports, etc.
• Provide excellent customer service to internal and external customers and business partners.
• Advocate to ensure Pie has a leading claims customer experience.
• Work to continuously improve claims operations and analyze opportunities and gaps in claim service, handling SOPs, protocols, and processes.

Requirements

• High School Diploma or equivalent is required.
• Bachelor's Degree or equivalent experience with some college coursework is preferred.
• Minimum 1 year of workers’ compensation claims experience as a Medical Only Adjuster is required.
• Minimum 1 year of experience handling California claims is required.
• Additional experience handling claims in Arizona and Utah is preferred.
• Proficient communication (written and verbal) skills to deliver information effectively.
• Awareness of individual tasks and how they impact team deliverables.
• Experience using G-Suite Tools and collaboration tools like Slack is preferred.
• Demonstrated knowledge and experience in claim adjudication and medical 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.

Compensation & Benefits

• Base Salary Range: $60,000 — $75,000 USD
• Comprehensive health plans
• Generous PTO
• Future-focused 401(k) match
• Generous parental and caregiver leave
• Discretionary performance bonuses