Sr. Workers Compensation Claims Adjuster

Job Description

Job Description

Position Summary:

This senior-level position is responsible for independently managing a caseload of medical treatment claims involving lost time, multiple body part injuries, and litigation in New Jersey and /or Pennsylvania. The adjuster manages the investigation, evaluation, and resolution of workers’ compensation claims in compliance with legal statutes, policy terms, and client-specific instructions. The adjuster coordinates medical care, negotiates settlements, and works closely with claimants, clients, attorneys, and medical professionals to achieve timely, cost-effective outcomes. This role involves training and mentoring fellow adjusters and peers to enhance their technical skills and support their career advancement. Additionally, it serves as a client advocate by addressing claim concerns and delivering consistent, high-quality service. This position is primarily hybrid or in-person; however, a  remote work option may be considered for candidates residing in NJ, PA, or DE.

Duties/Responsibilities:

• Independently manage a caseload of workers' compensation claims involving medical, indemnity and excess reportable claims.
• Investigate, evaluate, and resolve lost time claims in compliance with NJ and/or PA with applicable jurisdictional workers' compensation laws.
• Establish claim reserve levels by estimating the cost of each assigned claim; monitor reserves and update amounts as claim conditions evolve.
• Report to excess carriers in accordance with policy thresholds and contractual obligations.
• Coordinate with medical providers, nurse case managers, and legal counsel to ensure appropriate treatment and litigation strategy.
• Participating in client claim reviews, according to the needs of the client.
• Make timely compensability determinations in compliance with applicable jurisdictional laws.

• Document action plans, reserve changes, insurance coverage info, and SIR involvement.
• Identify potential fraud and alert management accordingly.
• Coordinate medical treatment, pre-authorizations, and review medical bills.
• Calculate and issue indemnity benefits, including death/dependency benefits in a timely and accurate manner.

• Prepare comprehensive reports and updates for clients and internal leadership.
• Communicate effectively with injured workers, employers, attorneys, and internal stakeholders.
• Facilitate round table discussions with peers regarding challenging claims.
• Maintain detailed and timely documentation in claims management systems.

• Negotiate claim settlements within authority and accurately process and track award payments.
• Maintain consistent and professional communication with claimants, providers, attorneys, employers, and clients.

Qualifications & Competencies:

• 7+ years of handling Medical Only/Workers’ Compensation claims.
• Public entity experience strongly preferred.
• Active or eligible to obtain required adjuster licenses.
• Strong attention to detail and investigative mindset.
• Excellent written, verbal, and interpersonal communication skills.
• Strong public speaking and presentation skills are essential.
• Proficient in Microsoft Office, web-based systems, and claims software.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.