Claims Specialist

• To analyze Medical Only & Lost-Times Workers Compensation claims on behalf of our valued clients to determine benefits due.
• Ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements.
• Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution.
• Investigating and gathering information to determine the exposure on the claim.
• Negotiating settlement of claims within designated authority.
• Communicating claim activity and processing with the claimant and the client.
• Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner.

Workers' Compensation Claims Adjuster

• Receives and processes claims including entering/verifying claims data
• Resolves claim edits and determines benefit eligibility
• Reviews payment levels and elevates issues to supervision as necessary
• Meets production and quality standards, ensuring timely and accurate work
• Maintains accurate records including timekeeping
• Attends all required training classes

Associate Claims Processor

• Codes and processes claims forms for payment ensuring all information is supplied before eligible payments are made.
• Researches and analyzes claims issues.
• Learning the activities/tasks associated with his/her role.
• Works under direct supervision.
• Relies on others for instruction, guidance, and direction.

Claims Processor I

• 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

• Receives and processes claims including entering/verifying claims data; determines if claim information is complete and correct.
• Resolves claim edits, reviews history records and determines benefit eligibility for service.
• Reviews payment levels to arrive at final payment determination; elevates issues to next level of supervision, as appropriate.
• Meets all production and quality standards, ensuring timeliness and accuracy of all work.
• Maintains accurate records including timekeeping records.
• Attends all required training classes.

Claims Processor

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Claims Specialist II

• Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim.
• Negotiating settlement of claims within designated authority.
• Communicating claim activity and processing with the claimant and the client.
• Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner.

Workers Compensation Claims Examiner – MD, VA, DC Jurisdictional Experience

• To process low level workers compensation claims to determine benefits due.
• Ensure ongoing adjudication of claims within company standards and industry best practices.
• Identify subrogation of claims and negotiate settlements with general supervision.
• Processes low level workers compensation claims determining compensability and benefits due on long term indemnity claims.
• Approves and processes assigned claims, determines benefits due and administers action plan pursuant to the claim or client contract.

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