Claims Manager - Modesto, CA

Job Summary:

The Claims Manager investigates, evaluates, and manages all workers'' compensation, general liability, and insurance claims for the company. This position is responsible for documentation of claims and circumstances, investigation of claims, assessment of liability and compensability, establishment of reserves and settlement values, and processing of claims through to closure. The Claims Manager works closely with the Director of Risk Management to prepare and present claims for settlement or closure. The Claims Manager possesses advanced analytical skills to identify and assess risks that have an impact on the company''s financial health, legal compliance, or reputation.

The incumbent collaborates with Company Leadership, Department Managers, Legal staff, and third-party administrators (TPAs) to report, administer, and resolve claims effectively. Additionally, the Claims Manager works closely with insurance brokers and vendors on company projects and initiatives. This position requires analytical skills and knowledge to review operational procedures, business data, loss trends, and present findings to internal and external stakeholders. The incumbent must possess strong knowledge of Workers'' Compensation, General Liability and insurance regulations in California and Nevada, along with demonstrated experience in claims management and reserve setting.

Responsibilites:

• Investigates claims through evidence gathering, witness interviews, incident report review, and documentation of claim circumstances.
• Evaluates claim validity and compensability by analyzing whether injuries arose out of and in the course of employment for workers'' compensation claims and assessing company legal liability for general liability claims.
• Establishes and adjusts claim reserves based on severity, exposure, and historical loss data as claims develop.
• Ensures timely reporting of claims to insurance carriers, third-party administrators, and regulatory agencies within statutorily required timeframes.
• Maintains compliance with state-specific workers'' compensation laws across California and Nevada jurisdictions, including meeting all filing deadlines, attending required conferences and hearings, and responding to regulatory inquiries.
• Represents the company at legal proceedings, program audits, vendor meeting, along with regulatory and court hearings.
• Analyzes claim trends and root causes to identify patterns in incidents across the store portfolio, such as slip-and-falls in particular locations, repetitive motion injuries in specific departments, or customer incidents related to product handling. Based on analysis, develops and implements corrective action plans and preventive measures. Coordinates with store operations, facilities, and safety teams to address hazardous conditions, implements training programs, and modifies procedures to reduce future claim frequency and severity.
• Works with retail, logistic, back-office support and corporate management on risk awareness on various policies and procedures.
• Communicates with employees and management on a regular basis about the needs and changes of the insured claims programs
• Oversees relationships with insurance carriers, third-party administrators, defense counsel, medical providers, and vendors. Selects and directs defense counsel for litigated claims, reviews legal bills for reasonableness, and monitors litigation strategy and outcomes. For workers'' compensation, coordinates medical treatment, authorizes care within established guidelines, and works with medical case managers to facilitate appropriate treatment and return-to-work programs.
• For workers'' compensation claims specifically, develops and implements modified duty and transitional work programs to return injured employees to work as quickly as medically appropriate. This involves coordinating with third-party administrators and store management to identify suitable temporary assignments, working with treating physicians to establish work restrictions, and monitoring employees'' progress through recovery.
• Develops and updates claim service instruction for third party administrators
• Controls claim costs through effective negotiation of settlements, medical bill review and negotiation, management of attorney fees and litigation expenses, and identification of subrogation opportunities. Prepares and manages the claims budget, tracks actual versus projected costs, and provides financial reporting on loss runs, claim reserves, and paid losses. Analyzes the financial impact of claims on insurance premiums and works to minimize experience modification rates.
• Provides training to store management and safety staff on proper incident reporting procedures, claims investigation techniques, and their roles in the claims process. Educates managers on what constitutes a compensable workers'' compensation injury, when to report incidents, and how to document events accurately.
• Serves as the primary point of contact for injured employees, claimants, store management, corporate leadership, and insurance partners. Provides regular status updates to stakeholders, explains claims processes and procedures, and manages expectations regarding claim outcomes and timelines.
• Liaison with Safety Team to Counsel/work with employees and locations with high claims rates to evaluate in-store safety program administration
• Works closely with the Safety team to develop safety programs that prevent injury or accidents, and ensure in-store safety programs are implemented and effective.
• Assists in the annual insurance renewal process and contribute to budget recommendations
• Provides program and administrative support to Director of Risk Management; may represent Director at meetings, etc.
• May lead projects, as assigned to improve existing programs
• Follows all safety policies and procedures
• Other duties as assigned