Workers Compensation Claims Adjuster

Workers’ Compensation Claims Adjuster – Lost Time Claims

Position Summary

We are seeking an experienced Workers’ Compensation Claims Adjuster to manage a caseload of lost time workers’ compensation claims.

This position is responsible for the full life cycle of assigned claims, including investigation, compensability decisions, reserving, medical management, litigation oversight, negotiations, and resolution. The Adjuster will primarily handle claims with total incurred exposure of $200,000 or less. Claims exceeding that exposure, as well as catastrophic claims, are referred to senior-level claims professionals.

The ideal candidate will have hands-on experience managing lost time workers’ compensation claims and be comfortable independently managing claims from initial investigation through resolution.

Qualifications

• Minimum of two years of workers’ compensation claims handling experience

• Experience handling lost time workers’ compensation claims

• South Carolina Workers’ Compensation Adjuster License required

• Bachelor’s degree preferred but not required

• AIC or similar insurance designation preferred but not required

• Strong investigation, reserving, negotiation, and claims management skills

• Knowledge of workers’ compensation statutes, regulations, and compliance requirements

• Ability to manage medical, legal, and vendor relationships

• Strong organizational, communication, and documentation skills

• Ability to exercise independent judgment when making claims decisions

Responsibilities

• Manage lost time workers’ compensation claims from initial report through resolution.

• Conduct thorough claim investigations and make compensability determinations.

• Establish and maintain appropriate claim reserves.

• Manage indemnity and medical payments on assigned claims.

• Monitor medical treatment, return-to-work efforts, and overall claim development.

• Ensure compliance with applicable workers’ compensation statutes and regulatory requirements.

• Ensure CMS Section 111 requirements are properly applied and reported through the designated vendor.

• Coordinate with attorneys, medical providers, nurse case managers, investigators, surveillance vendors, independent medical examination providers, and other claim-related vendors.

• Manage litigated claims and work closely with defense counsel to develop appropriate claim strategies.

• Attend mediations, informal conferences, hearings, and other claim-related proceedings as necessary.

• Evaluate claims for settlement opportunities and negotiate resolutions when appropriate.

• Monitor claim exposure and refer claims exceeding or reasonably expected to exceed $200,000 to the appropriate senior claims professional.

• Immediately identify and refer catastrophic claims when appropriate.

• Report qualifying claims to excess insurance carriers as required.

• Maintain accurate, timely, and comprehensive claim file documentation.

• Meet with claims coordinators at assigned member facilities at least annually.

• Provide guidance and assistance to less experienced claims professionals as needed.

• Assist senior claims leadership with special projects and departmental initiatives.

• Utilize approved technology and artificial intelligence tools to improve the efficiency, accuracy, and consistency of claims handling while maintaining confidentiality and independent professional judgment.

Travel Requirements

• Ability to travel for company business as needed, generally less than 25% of the time

• Reliable transportation required

• Valid driver’s license required

Additional Expectations

The Workers’ Compensation Claims Adjuster will maintain professional relationships with internal team members, clients, members, medical professionals, attorneys, and other business partners while providing responsive, high-quality claims service.

The position requires discretion, sound judgment, confidentiality, and a commitment to effective and timely claims resolution.