Claims Specialist

• Investigate and confirm the facts of loss for automobile accidents.
• Determine coverage, liability, damages and adjust and negotiate claims within limit of authority.
• Handle investigation regarding auto claims (coverage, liability and damages).
• Review, evaluate, and negotiate basic injury claims if handled.
• Recognize and identify body parts of a vehicle and understand other potential property damage.
• Identify customer needs and work to meet those needs using appropriate customer service skills.
• Determine subrogation or fraud potential and how to handle.

MD Claims Adjuster

• Responsible for working with repair facilities to validate, adjudicate, and approve payment for diagnostics and repair recommendations for pre-sale repairs as well as customer vehicles under warranty.
• Properly adjudicates claims within approval limit and in accordance with department & industry standards.
• Accurately notates all actions taken and interactions with shops and customers within internal systems ensuring proper documentation of interactions.
• Effectively navigates department resources in order ensure adherence to department process flows and policies.
• Manages list of assigned pending claims and provides timely follow up with repair facilities to decision claims.
• Other duties as assigned.

Mechanical Claims Adjuster

• 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

• Investigating and confirming facts of loss for automobile accidents
• Determining coverage, liability, damages, and adjusting claims
• Working Monday through Friday, 8 am to 5 pm Pacific Time

Claims Adjuster, Trainee

• Researching claims — auditing them for accuracy, compliance, and correct payment
• Managing escalated and complex claims issues
• Reviewing emails for encounters, outside vendors, and special projects
• Creating reports to track trends and quality opportunities
• Supporting mass adjustment efforts
• Acting as a go-to subject matter expert for tricky claim questions

Senior Claims Examiner

• To process low level general liability & bodily injury 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.
• 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.

Liability Claims Representative – GL, BI Experience, License Required

• Responsible for managing workers’ compensation claims as assigned by claims supervisor
• Investigates claims
• Determines the compensability of the claim and extent of liability
• Communicates directly with clients, employers, injured workers, physicians, and attorneys to bring claims to a timely conclusion
• Interviews, telephones, or corresponds with claimant and witnesses; consults police and hospital records
• Contacts physicians to obtain medical diagnoses and projected treatment plans
• Monitors medical progress of claimants and coordinates follow-up treatments; reports to employers including any restrictions that may be imposed on claimants’ return to work
• Documents all information from contacts with employers, claimants, physicians, and attorneys into the claims’ management system and ensures that documentation is current
• Calculates and sets reserves through a reserve worksheet including the nature and scope of claims; adjusts reserves to reflect ultimate known exposures
• Issues medical, indemnity, legal and expense payments
• Prepares reports for excess carriers and requests reimbursement when needed
• Sets reminders to follow-up on tasks through diaries on the system; reviews and completes diaries daily
• Maintains physical files for claim-related documents such as medical information, legal reports, and other correspondence
• Reviews claims’ submissions for thoroughness and accuracy
• Determines compensability of claims through information gathered and according to workers’ compensation statutes; makes recommendations as to compensability and coverage of claims
• Provides guidance and advice to clients on direction of claims after all information has been gathered and analyzed
• Ensures jurisdictional filings are complete and timely
• Obtains pre-certification approval for specific treatments as needed

Claims Examiner

• 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

• Research and resolve all claims and authorizations exceptions using internal resources.
• Provide communication to providers as necessary regarding the status of a claim or authorization.
• Follow up with providers on all financial implications of reprocessed claims or authorizations.
• Transport all claims entered by processors from image software to proprietary software for review.
• Utilizing knowledge of system, research current queues of work to find claims requiring further research and correction.
• Research and resolve any claim and authorization issues to determine best resolution.
• Work with internal departments to resolve issues involving authorization or claim handling.
• Recoup any overpayments to providers resulting from changes to a claim or authorization processing by posting to the provider account.
• Log all claims and authorizations that cannot be resolved and send rejection letters to providers.
• Using knowledge of authorizations, hold certain payments pending the outcome of client review.
• Adjudicate claims and send for payments ensuring that all proper documentation is attached.
• Complete daily audit of claims entered by Claim Intake representative.
• Take any incoming calls from providers or members regarding authorizations, benefits, or claim status.
• Provide backup to Accounts Receivable Assistant or Authorization Representative as needed.
• Develop and/or communicate methods to improve productivity and efficiency.
• Assist with gathering data for client audits.
• Contribute to the team effort by accomplishing additional responsibilities as needed.
• Assist with training of new staff members.

• Confirm coverage of claims by reviewing policies and documents submitted in support of claims
• Analyze coverage and communicate coverage positions
• Conduct, coordinate, and direct investigation into loss facts and extent of damages
• Evaluate information on coverage, liability, and damages to determine extent of insured's exposure
• Negotiate and settle claims either directly or indirectly
• Prepare reports by collecting and summarizing information
• Adhere to Fair Claims Practices regulations
• Assist in training and mentoring of specialists
• Participate in special projects or assist other team members as requested

Executive Claims Examiner

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