Claims Specialist

• Determine, evaluate, investigate, negotiate and resolve quota share and single insurer property claims
• Verify coverage under the applicable Commercial Property insurance policy
• Coordinate with field adjusters and experts for inspections or further investigation
• Review supporting documentation submitted for the claims and properly note the details of the review within the file
• Analyze damage estimates and repair costs as well as review vendor invoices for accuracy
• Identify potential issues such as fraud, duplicate claims, or policy exclusions
• Communicate with policyholders, adjusters, contractors, and other stakeholders regularly to ensure constant claim progression and keep all involved parties updated
• Prepare written status and large loss reports for clients, including Reservation of Rights and Coverage Position Letters
• Handle appeals or disputes related to claim decisions
• Attend mediations and settlement conferences as necessary
• Direct and monitor defense counsel to settle litigated claims
• Provide monetary authority and strategy to counsel to ensure client’s money and claims are protected
• Present and explain claim overviews to business partners on a monthly basis
• Participate in audits and quality control reviews
• Stay updated on industry trends, policy changes, and best practices

Commercial Property Claims Adjuster

• Investigate first party physical damage and third party liability claims to determine coverage, liability, and damages
• Review accident reports, witness statements, repair estimates, and related claim materials
• Conduct interviews with claimants, insureds, witnesses, and other involved parties
• Analyze policy provisions and coverage details to determine claim applicability
• Complete damages investigations including repair estimates, loss of use, diminished value, etc
• Issue payments in accordance with coverage, liability, and damages investigation, company policies, and client service standards
• Identify subrogation, or other risk transfer opportunities, and refer the file to the subrogation unit
• Manage assigned claims from initial report through resolution
• Establish and maintain appropriate claim reserves based on claim exposure
• Establish and maintain appropriate plan of action and file diary
• Evaluate damages including bodily injury, liability exposure, and property damage
• Negotiate settlements with claimants, attorneys, and other involved parties
• Process form letters
• Maintain regular communication with clients, insureds, claimants, and other involved parties
• Provide updates regarding claim status, strategy, and resolution progress
• Deliver high-quality customer service
• Maintain accurate and detailed claim documentation within the claims management system
• Ensure claim handling complies with company guidelines, regulatory requirements, and client service standards
• Identify potential fraud indicators and escalate concerns when appropriate

Liability Associate, Claims Adjuster

• Manages assigned claims for multiple jurisdictions.
• Works with defense counsel and third-party administrator to investigate and resolve claims.
• Helps facilitate questions regarding departmental policies.
• Assists hospitals with loss prevention programs.
• Assists in educating hospitals on state and federal agency standards and regulations.
• Prepares assigned reports.
• Has awareness of the Texas non-subscription program.
• Stays current via newspapers, periodicals, industry materials, associations, etc.
• Understands and utilizes company resources where appropriate.
• Networks with co-workers to share best practices.
• Understands different depts. and their role in the corporate office.
• Develops strategies and aligns work to achieve goals.

Workers Compensation Claims Coordinator

• Investigate and evaluate Florida workers’ compensation claims to determine compensability, exposure, and total claim value in accordance with Florida statutes and case law.
• Establish and maintain appropriate reserves using reserving tools, ODG guidelines, and company reserving philosophy.
• Initiate and manage indemnity payments and maintain diary systems for ongoing payments and claim activity.
• Complete state-required filings and EDI reporting accurately and within required timelines.
• Assign and coordinate with defense counsel on litigated claims and assist with litigation strategy.
• Collaborate with Nurse Case Managers to monitor medical treatment and authorize appropriate medical services under Florida Statute 440.13.
• Review and approve medical bills within required timeframes.
• Determine need for vocational rehabilitation services to assist injured employees with return-to-work planning.
• Coordinate light duty opportunities and workplace accommodations with employers and medical providers.
• Maintain consistent communication with clients and attend client meetings as required.
• Maintain accurate documentation, diaries, and workflow management to ensure regulatory compliance.
• Identify potential subrogation or recovery opportunities and pursue appropriate reimbursement from responsible parties.
• Protect Medicare’s interests and ensure compliance with MMSEA Section 111 reporting requirements.
• Monitor claims for red flags or potential fraud indicators.
• Request reimbursement from excess carriers as required and follow up on outstanding recoveries.
• Escalate client concerns or E&O risks to leadership when appropriate.
• Maintain performance expectations, including a 97% claim closure ratio.

Workers’ Compensation Claims Adjuster

• Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
• Negotiates settlement of claims within designated authority.
• Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
• Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level.
• Prepares necessary state fillings within statutory limits.
• Manages the litigation process; ensures timely and cost effective claims resolution.
• Coordinates vendor referrals for additional investigation and/or litigation management.
• Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
• Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
• Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
• Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
• Ensures claim files are properly documented and claims coding is correct.
• Refers cases as appropriate to supervisor and management.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travels as required.

Claims Examiner – Workers Compensation, Southeast Exp Preferred, Licensing: NC

• Investigate, analyze, and determine the extent of liability concerning first party homeowner property losses and damages.
• Effectively communicate and negotiate with policyholders, agents, public adjusters, attorneys, and service providers via phone, email, and internal systems to accurately document claim details.
• Successfully manage a pending claim load at varying stages of the claims process.
• Interpret and apply the details of an insurance policy to ensure the accuracy of payments and claims declinations.
• Interpret and apply computer generated loss estimates, engineer’s reports, and construction terminology.
• Update and maintain comprehensive claim handling notations in our electronic claims management system and other related applications.
• Mentor our mid and associate level claims representatives.

Complex Claims Representative

• Examining and appropriately interpreting insureds’ policies, forms in force, and other records to determine coverage and extent of the company’s exposure and policy limitations
• Applying knowledge of multiple state statutes, including the insurance code of ethics, rules, regulations, and guidelines
• Desk reviewing, drafting, adjusting, and approving estimates of damage and loss amounts for structural damages, mitigation, remediation, etc
• Using varying methods of investigation, including taking recorded statements, consulting with experts, identifying property damage, and reviewing documentation
• Keeping active communication and working with customers, their representatives, contractors, and experts throughout the Claims process from first notice of the claim through repair completion
• Working with public adjusters and attorneys that may represent the insured(s) and responding to all notices and letters in accordance with state guidelines

Senior Claims Adjuster, Large Loss

• Investigate, analyze, and determine the extent of liability concerning first party homeowner property large losses and damages of $100K+.
• Negotiate settlements and make payments within scope of authority, settling claims timely, and in the most cost-effective manner.
• Effectively communicate with policyholders, agents, and service providers via phone, email, and internal systems to accurately document claim details.
• Effectively manage loss and expense reserves to ensure accurate and timely reserving practices on all large loss claim exposures.
• Create and maintain comprehensive claim handling documentation in the electronic claims management system and related applications including the completion and escalation of Large Loss Reports (LLR’s).
• Ability to successfully manage a pending claim volume at varying stages in the claims process.
• Interpret and apply the details of an insurance policy to ensure the accuracy of payments and claims declinations.
• Ability to understand, computer generated loss estimates and construction terminology.
• Update and maintain comprehensive claim handling notations in our electronic claims management system and other related applications.

Claims Specialist – Large Loss

• Investigate and evaluate liability claims to determine coverage, liability exposure, damages, and appropriate resolution strategy
• Analyze claim exposure and recommend the proper course of action to achieve timely and appropriate settlement outcomes
• Set, monitor, and adjust claim reserves in accordance with established reserving practices
• Communicate effectively with insureds, claimants, attorneys, clients, vendors, and other involved parties throughout the claim lifecycle
• Develop and coordinate litigation and defense strategies with assigned defense counsel when applicable
• Negotiate settlements and manage claims through resolution in alignment with client expectations and authority levels
• Ensure all claims are handled in accordance with client guidelines, Davies (PGCS) policies and procedures, and applicable statutory, regulatory, and ethical requirements
• Maintain clear, accurate, and timely documentation of all claim activity to support defensible claim outcomes
• Plan, prioritize, and organize workload effectively to meet service level expectations and deadlines
• Embrace ongoing learning, feedback, and professional development in a dynamic claims environment

Liability Claims Adjuster

• Determine compensability and/or coverage issues for loss time workers' compensation claims.
• Effectively manage a caseload of loss time claims from numerous jurisdictions.
• Negotiate and direct settlements under management's review.
• Gather medical and factual evidence to determine compensability.
• Direct outside investigation and handle litigation files within given authority.
• Coordinate and maintain contact with claimants and/or their attorneys, outside investigators, and rehabilitation personnel as well as routine contact with insureds, account liaisons and medical providers.

Workers' Compensation Claims Representative

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