Claims Specialist

• Adjusts attorney-involved moderately complex bodily injury claims with demonstrable injuries (e.g. torn meniscus, broken bones, disc herniations), as well as all auto physical damage associated with those claims
• Identifies, confirms, and makes coverage decisions on moderately complex bodily injury claims
• Investigates loss details, determines legal liability, evaluates, negotiates, and arrives at claim settlement within appropriate authority guidelines
• Clearly documents thought process, investigation, evaluation, negotiation, and settlement decisions
• Prioritizes and manages assigned claims workload to keep members and other involved parties informed, provides timely claims status updates
• Collaborates and supports team members to resolve issues and identify appropriate matters for escalation
• Partners and/or directs vendors and internal business partners to facilitate timely claims resolution
• Supports workload surges and/or Catastrophe Operations as needed
• May act as an informal resource for team members with less experience

Senior Injury Claims Adjuster

• Analyze complex coverage issues, conduct detailed investigations, and evaluate damages and liability to determine the validity of moderate to highly complex commercial property and casualty claims
• Handle high-exposure property losses, including large commercial building, business personal property, business interruption, inland marine, equipment breakdown, crime, and bond claims
• Investigate and evaluate third-party casualty claims, including general liability, premises liability, product liability, contractual liability, and bodily injury/property damage claims
• Formulate and issue formal coverage position letters and liability determinations based on policy language, facts, and applicable legal principles
• Conduct comprehensive investigations, including interviews of insureds, claimants, witnesses, and other involved parties to determine coverage, liability, causation, and damages
• Coordinate and manage field investigations, site inspections, scene examinations, and independent adjuster assignments as necessary
• Identify, retain, and manage experts including engineers, building consultants, forensic accountants, cause-and-origin specialists, medical professionals, accident reconstructionists, and defense counsel to support claim resolution
• Review and analyze repair estimates, contractor bids, engineering reports, medical records, litigation documents, and expert evaluations to determine the extent of damages, liability exposure, and appropriate claim disposition
• Assess comparative negligence, liability defenses, subrogation opportunities, and risk-transfer provisions where applicable
• Establish, monitor, and recommend appropriate reserves based on claim complexity, damages, liability exposure, and settlement potential
• Develop and execute claim resolution strategies for large-loss and high-severity claims, including those with significant litigation potential
• Collaborate with defense counsel and litigation management teams on litigated matters, monitoring case strategy, budgets, exposure assessments, and settlement opportunities
• Prepare detailed large loss and management reports summarizing coverage positions, liability assessments, damage evaluations, reserve adequacy, and settlement recommendations
• Present claim evaluations and settlement recommendations to management for claims exceeding assigned authority limits
• Negotiate fair and timely settlements with insureds, claimants, attorneys, contractors, and other parties within delegated authority
• Communicate effectively with insureds, agents, brokers, claimants, attorneys, and internal business partners to provide superior customer service and ensure transparency throughout the claims process
• Manage a high-volume and complex caseload while maintaining proactive diary management and meeting all regulatory and company service standards
• Maintain complete, accurate, and organized claim files in accordance with company policies, best practices, audit standards, and regulatory requirements
• Identify trends, emerging risks, and exposure concerns and provide recommendations to management regarding claim handling strategies and risk mitigation opportunities

Senior Claims Adjuster, Property and Casualty

• The position of Care Advocate will play a leading role in developing an innovative digital product strategy based off your deep expertise and knowledge of the long-term care needs of the aging in your market.
• You will be part of a team delivering concierge services care-seekers and care-managers including but not limited to Caregiver support and Education.
• Conducting consultations with older adults and caregivers on aging services and supports providing support and guidance on the caregiving journey.
• Unlike other traditional Care Advocacy roles, your responsibilities will not stop there but will extend to working with digital product teams to help infuse your patient-centered knowledge into the design process and provide feedback that will help create incredible digital user experiences for millions of care-seekers and care-managers at a tremendous scale.
• This role will provide Subject Matter expertise on the local and state level programming and resources for aging adults and their caregivers.
• This role will provide education and resources to aging individuals seeking assistance with care options and navigating challenges.
• Intensive case management experience and crisis intervention.
• Approach problem-solving with a human-centered lens.
• Regular document key and frequent needs of users and report qualitative data (such as quotes and anecdotal stories that representative of user needs) and quantitative data (such as frequency of user needs and trends in gaps in local care environments and resources) to the digital product and design teams.
• Bring deep understanding of landscape and individual aging and long-term resources, facilities, organizations, agencies, and referral sources to help marketing team reach key partnerships and potential consumers who would benefit from our digital products.
• Report back to product and design teams opportunities for improvement of the digital products based off of user feedback.
• Review new product features before they are released to consumers to identify improvements or potential issues to proactively improve user experience.

Associate Claims Clinical, Care Advocacy

• Demonstrate the ability to independently and timely manage all aspects of the most complex, high-value claims while exhibiting a detailed knowledge of the claim, a well-reasoned analytical focus and a clear strategy for resolution
• Provide proactive communications to customers and business partners in the management and resolution of claims
• Respond to inquiries from customers and provide superior customer service
• Review and analyze multiple complex policies and coverage parts (including general liability and umbrella/excess liability)
• Write and articulate clear, concise and accurate coverage positions
• Conduct investigations regarding claims and/or lawsuits
• Effectively manage litigation and counsel, inclusive of litigation planning/budgeting, and proactively position claims for resolution
• Develop and persuasively articulate complex coverage, liability and damage assessments
• Provide detailed impactful recommendations to leadership
• Pursue and finalize coverage and liability risk transfer against other liable parties and insurance carriers
• Conduct complex negotiations and articulate coverage/liability positions
• Attend mediations and trials as necessary
• Proactively manage accurate expense, reserve and financial transactions
• Consistently maintain up-to-date claims metrics

Claims Specialist – Latent Bodily Injury

• Provides exceptional service to Harbor Claims external and internal customers
• Utilizes tact, diplomacy and professional communication skills to positively represent Harbor Claims in telephone and email contacts
• Appropriately and correctly responds via telephone and email interactions to a wide range of policyholders’, agents’ and third party representatives’ claims
• Successfully coordinates with field adjusters and provides professional and responsive assistance and follow-up inquiries on pending claims
• Requests, obtains, reviews, and evaluates outside experts’ opinions
• Investigates claims; analyzes claims information to determine appropriate settlement
• Communicates with claimants regarding settlement and effectively negotiates
• Maintains exceptionally thorough, accurate claims files in compliance with governmental regulations and Company standards
• Reviews assigned files for subrogation potential

Claims Analyst II/III – Residential Property

• Utilize in-depth knowledge of vehicle mechanics to evaluate, investigate, and process mechanical claims accurately and efficiently.
• Communicate via telephone and email with vehicle contract holders, repair facilities, and other parties.
• Actively listen to callers’ questions and concerns, demonstrating empathy and compassion.
• Adhere to all established department processes and utilize company-specific computer systems.
• Collaborate with leaders and other claim analysts to consistently uphold the company’s reputation.

Bilingual Automotive Claims Specialist – Spanish/English

• Acquire and apply basic knowledge of auto coverage, auto physical damage, and liability, in order to evaluate and settle high volume and low complexity auto claims
• Resolve claims through proactive problem solving and decision making, within authority guidelines and under direct supervision
• Clearly document thought process including damage evaluation, investigation, negotiation, and settlement decisions
• Collaborate and set expectations with external and internal business partners to facilitate claims resolution
• Support members, business partners, and claimants, through use of varying communication channels to include utilization of digital tools to drive timely and effective resolutions

Entry-Level Auto Claims Adjuster

• Speak compassionately to homeowners about their homeowner's insurance claims/loss drafts
• Processing and monitoring all insurance claims/loss drafts
• Handling of claims funds for disbursements to pay for repairs
• Develop workable solutions that satisfy our homeowners, our client/investors, and our company
• Work in multiple systems, such as MS, MSP, and Encompass
• Strong verbal and written communication skills to communicate with homeowners about their claims/loss drafts
• Strong organizational skills
• A strong work ethic, high integrity, and well-organized mindset
• The ability to follow instructions but work with minimal direct supervision
• Ability to meet deadlines in a timely fashion

Insurance Claims Specialist

• Responsible for leading and managing a team of claims examiners
• Ensure accurate, compliant, and timely processing of medical claims
• Serve as a critical bridge between frontline operations and leadership
• Drive performance against SLAs, quality standards, and productivity targets
• Accountability for team performance, coaching and development, and process improvement
• Ensure adherence to Medicare regulations and CMS guidelines
• Oversee day-to-day medical claims processing
• Monitor and manage service level agreements (SLAs), turnaround times, and production
• Apply deep working knowledge of CMS regulations, Medicare auditing standards, and payer guidelines
• Review claims and audit results to identify trends and training opportunities
• Analyze and manage key performance indicators including quality scores, error rates, productivity, and attendance
• Prepare and present operational and business reviews
• Identify operational risks, performance gaps, and improvement opportunities

Claims Examiner Team Leader

• Manages mid to complex Auto and/or General Liability claims, including bodily injury and property damage
• Handles litigated files and works with delegated authority
• Receives claims, confirms policy coverage and acknowledgment of the claim
• Determines validity and compensability of the claim
• Investigates claims and handles Auto and/or General Liability claims
• Establishes reserves and authorizes payments within reserving authority limits
• Communicates claim status with the customer, claimant, and client
• Adheres to client and carrier guidelines and participates in claims review as needed
• Collaborates with team members on more complex or problematic claims as necessary
• Additional duties as assigned

Senior Liability Claims Specialist

• Manages an inventory of moderate to high complexity and exposure commercial claims by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits.
• Provides exceptional customer service by interacting professionally and effectively with insureds, claimants and business partners, achieving quality and cycle time standards, providing regular, timely updates and responding promptly to inquiries and requests for information.
• Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language and partnering with coverage counsel on more complex matters, estimating potential claim valuation, and following company's claim handling protocols.
• Conducts focused investigation to determine compensability, liability and covered damages by gathering pertinent information, such as contracts or other documents, taking recorded statements from customers, claimants, injured workers, witnesses, and working with experts, or other parties, as necessary to verify the facts of the claim.
• Establishes and maintains working relationships with appropriate internal and external work partners, suppliers and experts by identifying and collaborating with resources that are needed to effectively resolve claims.
• Authorizes and ensures claim disbursements within authority limit by determining liability and compensability of the claim, negotiating settlements and escalating to manager as appropriate.
• Contributes to expense management by timely and accurately resolving claims, selecting and actively overseeing appropriate resources, and delivering high quality service.
• Identifies and addresses subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Recovery or SIU resources for further investigation.
• Achieves quality standards on every file by following all company guidelines, achieving quality and cycle time targets, ensuring proper documentation and issuing appropriate claim disbursements.
• Maintains compliance with state/local regulatory requirements by following company guidelines and staying current on commercial insurance laws, regulations or trends for line of business.
• May serve as a mentor/coach to less experienced claim professionals
• May perform additional duties as assigned.

Complex Claims Specialist – Professional Liability, Real Estate

• Investigate and confirm facts of loss for advanced automobile accidents.
• Determine coverage, liability, damages, and negotiate claims.
• Review, evaluate, and negotiate moderate injury claims as applicable.
• Recognize and identify vehicle body parts and potential property damage.

Bodily Injury Claims Adjuster

• Evaluate, investigate, negotiate and resolve commercial / agricultural property claims in accordance with legal, regulatory and internal standards.
• Verify coverage under the applicable 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.
• Conduct prompt, accurate investigations of liability claims, interview all relevant parties to obtain loss events facts and to establish liability; handle claims files to final resolutions.
• Analyze claim exposures, determine the proper courses of action, and appropriately settle claims, evaluating evidence by interpreting facts within applicable legal frameworks to determine liability and claim values.
• Develop settlement/litigation/defense strategies by evaluating factual information to settle claims in a cost-effective manner; work with defense attorneys and the client per account handling guidelines.
• Document and communicate all claim activity timely and effectively which supports the outcome of claim files, in accordance with established procedures; develop and maintain a progressive plan of action.
• 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.
• Utilize a diary system effectively and appropriately to keep claims files current.
• Examine and address claim files reserves for accuracy.
• Effectively identify, evaluate, and handle risk transfer on liability claims.
• Attend mediations and settlement conferences as necessary.
• Stay updated on industry trends, policy changes, and best practices.
• Maintain current knowledge of laws and statutes pertinent to liability claims handling, maintain CEUs and licensing in current and/or active status, as appropriate.
• Perform other duties as assigned.

Property and Liability Claims Adjuster

• Provide reassurance and assistance to make a difference in our customers' lives.
• Guide policyholders through the complicated medical aspects of auto insurance claims.
• Investigate medical necessity, determine casualty, evaluate the validity of personal injury insurance claims, and monitor case files over the course of treatment.
• Consult with involved parties (customers, other carriers, attorneys, medical providers) and secure medical information.

Personal Injury Claims Examiner

• Proactively manages assigned claims caseload comprised of complex damages that require commensurate knowledge and understanding of claims coverage including potential legal liability
• Partners with vendors and internal business partners to facilitate complex claims resolution
• Investigates claim damages by conducting research from various sources, including the insured, third parties, and external resources
• Identifies coverage concerns, reviews prior loss history, determines and creates Special Investigation Unit (SIU) referrals, when appropriate
• Determines and negotiates complex claims settlement within authority limits
• Develops recommendations and collaborates with management for determining settlement amounts outside of authority limits
• Maintains accurate, thorough, and current claim file documentation throughout the claims process
• Utilizes platforms and tools to prepare claims estimates to manage complex property insurance claims
• Supports workload surges and catastrophe (CAT) response operations as needed, including mandatory on-call dates and potential evening, weekend, and/or holiday work outside normal work hours
• May be assigned CAT deployment travel with minimal notice during designated CATs
• Works independently solving complex problems with minimal guidance

Property Adjuster Specialist – Specialty Claims Team

• Audit, review, and adjust medical, dental, and flexible spending accounts and Health Reimbursement Account claims.
• Review, apply and create refund letters for all lines of business to members and providers.
• Reprocess payments when necessary.
• Communicate with members, providers, employer group contacts, and other inquirers pertaining to specific refund questions.
• Review plan documents for various groups to research and resolve claim processing questions and issues.
• Act with urgency to respond to inquiries regarding refund request status-including research and resolution regarding outstanding request.
• Perform other related duties, as assigned.

Healthcare Claims Refund Specialist

• Perform claims analysis related to disputes, legal matters, state complaints, provider inquiries, and internal team inquiries
• Determine whether any claim payment or denial issues are present
• Submit the necessary documents to specific areas to ensure all is updated and corrected
• Submit all projects and/or claims to be reprocessed
• Perform education for providers, both internal and external, when required
• Attend provider group meetings, as well as individual meetings, both internally and externally
• Submit projects within Microsoft Excel as assigned
• Perform other duties as needed

Senior Claim Data Specialist, Provider Claims

• Manages an inventory of low to moderate complexity and exposure commercial claims by following company protocols
• Contributes to customer satisfaction by interacting professionally and effectively with insureds, claimants and business partners
• Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language
• Exercises judgement to determine liability and compensability by conducting investigations
• Works with appropriate internal and external partners to facilitate best claim outcomes
• Authorizes and ensures claim disbursements within authority limit by determining liability and negotiating settlements
• Identifies and addresses subrogation/salvage opportunities or potential fraud occurrences
• Maintains compliance with state/local regulatory requirements

Workers Compensation Claims Representative

• Provides quality investigation and analysis to adjust claims at all levels to proper resolution
• Promotes the success of the organization through development and advancement of relationships with agencies, policyholders and employees
• Collaborate proactively with agents, policyholders and internal stakeholders on claims and book of business as needed
• Investigate losses, identify coverage, evaluate liability and damages
• Develop plan of action to proactively conclude claims, timely evaluate damages, engage other parties in negotiations and settle claims pursuant to guidelines and delegated authority
• Leverage past experience to review and analyze documents
• Establish and maintain proper reserves for each claim to accurately reflect the financial exposure
• Determine need for, identify and engage external resources as needed to execute proper resolutions while monitoring and controlling costs
• Review and interpret commercial insurance policies and accordingly communicate coverage issues verbally and in writing.

Senior Auto Physical Damage Claims Representative

• Investigate and resolve Homeowners claims of moderate complexity in a prompt and efficient manner.
• Document with photographs, measurements, recorded interviews as needed, write a repair estimate to capture damages, and complete thorough file notes.
• Ability to use imagery and advanced video technology to collaborate with onsite vendors and insureds to identify damage and write damage estimates from a virtual setting.
• Compare facts gathered during the investigation against the policy to determine coverage of claim; extend or deny coverage as appropriate.
• Establishes reserve amounts within prescribed settlement authority limit and negotiates settlement of claims; recommends claims which exceed personal authority limit to supervisor for approval.
• Responsible for effectively and timely communicating with insureds and /or their representatives to resolve issues and ensure customer satisfaction.

Claims Specialist jobs in Florida

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