Medical Claims Adjuster - California

Medical Only Claims Adjuster - California

United States

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 Medical Only 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.

Claims Technical Management:

• Independently handle all aspects of the workers’ compensation medical only claims from set‑up to closure.
• Conduct timely 2‑point contact investigation, with focus on continued medical management, potential for lost time benefits, and claim closure 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 benefits throughout the life of the claim.
• Use Utilization Review where appropriate and pay medical bills within the allotted time frames.
• Comply with all applicable statutory guidelines, rules, and regulations.
• Proactively identify and timely assign 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 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.

• High School Diploma or equivalent is required.
• Bachelor’s Degree or equivalent experience with some college coursework is preferred.
• Minimum of 1 year’s workers’ compensation claims experience as a medical only adjuster is required.
• Experience in the following states preferred due to higher volume: CA, AZ, UT and TX.
• Proficient communication (written and verbal) skills to deliver information effectively.
• 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.
• 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.

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…