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Role Description

As a First Party Medical Claims Adjuster, you’ll be responsible for investigating and resolving first-party medical claims across multiple states. You’ll work closely with policyholders, medical providers, and internal teams to ensure claims are handled accurately, efficiently, and in compliance with state regulations and company guidelines.

• Conduct thorough investigations, including reviewing coverage, taking recorded statements, and gathering supporting documents such as police reports, repair estimates, and medical records.
• Communicate with claimants to explain benefits, eligibility, required forms, and claim procedures.
• Identify and refer potential fraud indicators to the Special Investigations Unit (SIU).
• Evaluate and recommend approval or denial of claims based on policy language, state statutes, and investigative findings.
• Ensure timely and accurate resolution of claims in accordance with company and regulatory standards.
• Review and respond to correspondence and medical bills in a timely manner.
• Maintain accurate and detailed claim files and documentation.

Qualifications

• High School Diploma or Equivalent
• Professional Insurance and/or Claims Designations are a plus.

Requirements

• An active Texas or Florida Adjuster License will be required to comply with state and GAINSCO requirements.
• Upon hire, additional license(s) may be required. If that is the case, license(s) must be obtained.
• All licenses must be maintained in accordance with state requirements.
• A minimum of 1 year of experience as an Auto Insurance Claims Adjuster is required.
• Experience with 1st Party Medical Claims is preferred.
• Experience with medical coding and/or medical billing a plus.
• Experience with Guidewire, Decision Point, and other claims systems preferred.
• Strong verbal and written communication skills.
• Excellent attention to detail and organizational skills.
• Ability to manage multiple tasks and prioritize effectively.
• Analytical thinker with the ability to draw conclusions and make sound recommendations.
• Calm and professional demeanor when handling challenging situations.

Benefits

• Excellent benefits package: medical & dental, vision insurance, life insurance, short-term and long-term disability insurance.
• Parental Leave Policy
• 401K + Company Match
• PTO Plan + Paid Company determined Holidays.