Claims Specialist

• Investigate and resolve claims within assigned authority
• Determine coverage and liability
• Negotiate settlements with insureds, claimants, and attorneys
• Maintain accurate documentation and reserving
• Communicate promptly and professionally with all stakeholders
• Collaborate with internal teams and external partners
• Adhere to audit and compliance standards
• Participate in training and team initiatives

Senior Claims Representative

• Perform all activities associated with the settlement of claims on Individual Disability insurance policies and riders, and disability waiver and ASR riders on Life insurance policies.
• Determine and request medical, financial and occupational claim requirements, obtain appropriate claim documents, interact with clients, advisors and outside vendors.
• Review information submitted to determine disability status, benefit eligibility and benefits.
• Make claim payment and manage the claim over the life of the client's claim.
• Manage relationships by providing clients and advisors with clear understanding of requirements and status of claim.
• Communicate clearly and completely regarding the handling of the claim.
• Adjudicate timely claim payments by determining the type and amount of the claim, verify status of the insurance policy and riders, confirm policy provisions.
• Request and analyze medical, financial and occupational claim requirements; coordinate investigative efforts ensuring appropriate referral of claims to internal resources and outside vendors.
• Provide thorough review of contestable claims.
• Thoroughly and accurately document the claim file with subjective, objective, analysis and plan information.
• Understand and comply with Fair Claim Handling requirements, state regulatory requirements, insurance law and legal/compliance procedures related to contracts and insurance claims in general.
• Identify claim risk and red flags, mitigating such risk during adjudication of the claim.
• Perform secondary review and approval of peer claims within authorization level.
• Handle claim referrals from team members and assist with complex claims as necessary.
• Provide peer feedback and input to manager.
• Provide input to improve processes and procedures; participate in improvement initiatives.

Senior Disability Claims Analyst

• Analyze and determine claim payments in an accurate and timely manner
• Claim decisions on non-complex disability claims
• Communicate clearly and professionally via phone and email
• Build and maintain strong relationships with internal and external stakeholders.
• Participate in team-based problem-solving and continuous improvement initiatives.
• Manage assigned work queues within defined service level agreements (SLAs).
• Support additional projects and responsibilities as needed.

Claims Analyst – Leave & Disability

• To analyze workers compensation claims on behalf of our valued clients to determine benefits due, while 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 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.

Claims Examiner – Workers Compensation I

• To process low level general liability claims to determine benefits due
• To ensure ongoing adjudication of claims within company standards and industry best practices
• To identify subrogation of claims and negotiate settlements with general supervision
• Processes low level general liability claims by gathering information to determine liability exposure
• Assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level
• Develops and coordinates low level general liability claims' action plans to resolution, return-to-work efforts, and approves claim payments
• Approves and processes assigned claims, determines benefits due, and administers action plan pursuant to the claim or client contract
• Performs other duties as assigned
• Supports the organization's quality program(s)
• Travels as required.

Claims Representative – Liability

• 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

• File proof of claims in bankruptcy courts by performing the following processing tasks as needed: Ensure the information on the claim form is accurate and complete
• Signing claims as an authorized representative/agent of the Company and Clients
• Copy claims for record retention purposes
• Participate in performing quality control validations of data to meet internal and client requirements to ensure proofs of claims are accurate and complete
• Process and redact client statements to support our claim filing needs as necessary in a secondary role/back-up capacity to Sr. Claims Specialist and or BKY Document Liaison
• Research missing bankruptcy data in PACER to ensure all case information is properly updated in our system
• Assist with any necessary post claim documents (Amending Claims, etc.) to assist with business operations for DCMS and Forte
• Understand and adhere to Company information, security and privacy responsibilities as detailed in the Information Resource Usage Policy, Employee Manual, and client-specific publications
• Other duties as assigned

Bankruptcy Claims Specialist

• Supports Revenue Cycle Operations, Coding Leadership, and other team members by reviewing electronic and written documentation.
• Convert documentation into diagnostic and/or procedure codes for reimbursement.
• Manage denials for third-party payers and oversee the denial process.
• Identify opportunities for workflow improvements.
• Communicate with clinical staff for accurate translation of medical record documentation using appropriate code selection.
• Assist in performing quality data collection and monitoring/reporting to ensure proper reimbursement.

• Reviewing and processing fraud‑related claims, primarily involving check transactions
• Ensuring all required documentation is received
• Evaluating claims to determine whether they should be honored or denied based on applicable criteria
• Taking appropriate account actions
• Debiting customer accounts or general ledger accounts when applicable
• Locating and tracking available funds
• Partnering with internal teams to support claim resolution and fund recovery
• Ongoing communication with internal stakeholders is required to coordinate claim decisions, account activity, and fund movement.

Claims Processor

• Prepare, update, and submit stop loss filing packages, including initial, subsequent, and year-end filings as needed
• Track claim activity and follow up through to completion with stop loss carriers and other stakeholders to help ensure reimbursements are received accurately and timely
• Monitor assigned employer groups and clients using reports, analysis, and reimbursement activity trends
• Assist in researching and reconciling discrepancies between requested reimbursement amounts and amounts returned by stop loss carriers
• Serve as an advocate for clients by helping capture the maximum eligible reimbursements available under applicable stop loss policies
• Review claim documentation for completeness, accuracy, and alignment with policy provisions and filing requirements
• Research and resolve cases that require additional analysis, documentation, or explanation
• Communicate with internal and external stakeholders to obtain information, resolve issues, and support timely filing resolution
• Partner with cross-functional teams, including areas such as underwriting, finance, eligibility, and client support, to facilitate filing resolution
• Maintain accurate records, logs, and supporting documentation related to assigned stop loss filings and reimbursements
• Escalate complex issues or delays appropriately and support process improvement efforts when trends or gaps are identified

Stop Loss Claims Analyst

• To analyze and process low to mid-level auto total loss and transportation claims.
• Processes total loss claims; assesses damage, makes payments, and ensures claim files are properly documented and correctly coded based on the policy.
• Develops and maintains action plans to ensure state required contract deadlines are met and to move the file towards prompt and appropriate resolution.
• Identifies and pursues subrogation opportunities; secures and disposes of salvage.
• Communicates claim action/processing with insured, client, and agent or broker when appropriate.
• Maintains professional client relations.
• Performs coverage, liability, and damage analysis on all claims assignments.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travels as required.

Claims Representative, Auto – Total Loss

• Manage a book of pending claims through effective time management to ensure timely payments
• Process decisions on claims through claim management system (Promise 360) and/or new business application (Compass)
• Approve and deny claim payments within authorization limits
• Render decisions on disability extension requests and traumatic injury claims within authorization limits
• Obtain necessary information for claim decisions from various sources including, but not limited to, the Veterans Administration, branches of service, beneficiaries, attorneys, and police departments.
• Correspond with claimants, law department, underwriting, Casualty Assistance Officers, attorneys, the Veterans Administration, and other interested parties through the life of a claim
• Prioritize work to ensure meeting of performance standards
• Other duties as assigned

Claims Examiner

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Claims Specialist II

• Manage a caseload of General Liability Claims (premises and construction defect) in multiple states
• Manage new loss assignments, reassignments and proper, timely reserve setting
• Perform coverage analysis, responsibilities to defend and/or indemnify, and choice of law
• Identify issues that need to be investigated and resolved
• Draft complex coverage position letters
• Develop legal strategy with counsel and manage General Liability litigation
• Identify appropriate cases for trial and complete pre-trial reports and trial activities
• Utilize artificial intelligence tools and resources

GL Claims Adjuster III

• Manage a caseload of complex legacy and long-tail Pollution and Environmental liability claims
• Handle new loss assignments and reassignments promptly
• Evaluate claim exposures and negotiate resolutions
• Support team initiatives with research on emerging pollution trends

Pollution Claims Adjuster III

• Manage a caseload of complex asbestos accounts
• Timely claim management of new loss assignments and reassignment
• Develop account strategy and manage mass tort litigation
• Evaluate asbestos cases
• Provide defense counsel and vendor oversight based upon an agreed litigation strategy
• Identify appropriate cases for trial and complete pre-trial and trial activities
• Understand coverage issues and make complex coverage decisions
• Gather and analyze claim trend, billing and other claim and financial data

Claims Adjuster III

• Manage a caseload of GL/Excess Claims in multiple states
• Perform coverage analysis and manage new loss assignments
• Identify issues and develop legal strategy with counsel
• Utilize artificial intelligence tools for claims management

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