Senior Lost Time Claims Adjuster

Position Summary

The Senior Claims Adjuster independently manages complex, high-exposure, and litigated Workers’ Compensation lost-time claims in assigned jurisdictions, including Pennsylvania, Delaware, and New Jersey. The role applies advanced compensability, medical, disability, reserving, litigation, settlement, and regulatory knowledge to develop and execute claim strategies through timely and cost-effective resolution. The Senior Claims Adjuster also serves as a technical resource, supports client relationships, mentors developing adjusters, and contributes to claim quality and continuous improvement initiatives.

Role Distinction

This is an advanced individual-contributor position. The Senior Claims Adjuster is expected to perform the complete Lost Time Adjuster role independently while demonstrating broader technical judgment, ownership of complex files, client-facing capability, mentoring, and measurable contribution to team performance. The position does not include formal supervisory authority unless separately assigned.

Key Responsibilities

• Independently investigate, evaluate, and manage complex, high-exposure, and litigated Workers’ Compensation lost-time claims through resolution.
• Determine compensability by conducting timely investigations, obtaining recorded statements, reviewing claim facts and employment information, and applying jurisdictional requirements.
• Develop, document, and regularly update strategic action plans addressing compensability, medical treatment, disability, return to work, reserves, litigation, recovery opportunities, and resolution.
• Coordinate and monitor medical treatment; review medical documentation; communicate with providers; and apply appropriate medical and impairment guidelines, including applicable AMA standards.
• Coordinate return-to-work and workplace accommodation efforts with injured employees, employers, medical providers, vocational resources, and internal stakeholders.
• Establish, document, and maintain reserves based on current exposure, probable outcomes, medical and disability information, litigation posture, and resolution strategy.
• Calculate and issue indemnity payments and review or approve medical payments within assigned authority and applicable jurisdictional requirements.
• Manage litigation in partnership with defense counsel, including strategy, budgets, discovery, expert resources, hearings, mediations, trials, settlement evaluation, and timely counsel direction.
• Conduct in-depth exposure analyses and develop resolution strategies for challenging, high-exposure, and litigated claims.
• Negotiate settlements within assigned authority and prepare well-supported authority requests when additional approval is required.
• Identify and pursue subrogation, recovery, contribution, coordination-of-benefits, and other cost-containment opportunities when applicable.
• Prepare and file required jurisdictional forms and maintain compliance with statutory, regulatory, client, carrier, and organizational requirements.
• Maintain accurate and timely claim documentation, action plans, diaries, financial transactions, correspondence, and activity notes in Spear.
• Provide clear claim status updates, exposure analyses, and strategic recommendations to clients and carriers.
• Prepare claim summaries and lead or meaningfully contribute to client claim-review and stewardship discussions.
• Develop and maintain strong client relationships through proactive communication, reliable follow-through, sound judgment, and solution-oriented service.
• Coordinate vendor resources, including nurse case managers, vocational specialists, investigators, bill-review resources, and other approved service providers.
• Mentor developing adjusters on claim-handling standards, statutory compliance, investigation, documentation, reserving, litigation, and resolution strategies.
• Serve as a technical resource for complex files and share knowledge through peer consultation, training, file discussion, and process-improvement activities.
• Participate in quality-assurance reviews, audits, corrective actions, special projects, client implementations, and operational improvement initiatives as assigned.
• Consistently meet established quality, timeliness, service, compliance, productivity, and financial performance standards.
• Adhere to organizational procedures and support team, client, and operational objectives.
• Additional job duties as assigned.

Senior-Level Capability Requirements

• Advanced technical judgment in compensability, medical management, disability, reserving, litigation, settlement, and jurisdictional compliance.
• Ability to independently prioritize and manage complex inventories while maintaining timely and accurate claim activity.
• Ability to identify material exposure changes, escalate appropriately, and present clear recommendations supported by claim facts and financial analysis.
• Demonstrated effectiveness in litigation strategy, counsel management, settlement negotiation, and client communication.
• Ability to mentor peers constructively without formal supervisory authority.
• Ability to identify and contribute to claim-quality, workflow, cost-containment, and service improvements.

Minimum Education/ Abilities/Skills

• High school diploma or GED required; college coursework or degree preferred.
• Minimum five years of progressively responsible Workers’ Compensation lost time claims-handling experience, including experience with complex or litigated claims.
• Required adjuster licenses and continuing education for assigned jurisdictions must be maintained in good standing.
• Demonstrated proficiency in compensability investigation, medical and disability management, benefit calculation, reserving, litigation, settlement, and regulatory compliance.
• Strong written and verbal communication, negotiation, analytical, organizational, prioritization, and time-management skills.
• Ability to build effective relationships and collaborate with clients, carriers, injured employees, employers, medical providers, counsel, vendors, and internal teams.
• Ability to manage multiple priorities, meet deadlines, adapt to change, and perform effectively under pressure.
• Proficiency in Microsoft Office and claim-management systems; Spear experience preferred.
• Demonstrated commitment to client service, knowledge sharing, continuous learning, and operational improvement.

Compensation

• The base salary range for this position is $75,000 to $85,000 annually, depending on experience. Individual compensation will also be determined based on a variety of factors, including skills, education, and internal equity.

Originally posted on Himalayas