Claims Specialist

• Investigate, evaluate, negotiate and resolve commercial general liability claims in a fair and timely manner.
• Thoroughly evaluate and analyze coverage and draft comprehensive coverage position letters.
• Manage the defense of more complex regional commercial general liability claims in multiple jurisdictions in accordance with leading practices.
• Manage non-litigated and some litigated claims.
• Operate on an independent basis with little supervision and settle claims within assigned authority.
• Effectively manage expenses.
• Attend mediations, trials and hearings as needed to include interaction with insureds, agents, and legal representatives.
• Review court decisions, laws and coverage interpretations and have a broad knowledge and understanding of the law and claim practices.
• Able to work independently and serve as a mentor to lesser experienced team members.

Commercial Lines Claims Specialist – Commercial General Liability

• Investigate and handle personal and commercial auto bodily injury claims of a complex and serious nature
• Perform special claims investigations and handle matters requiring broad technical claims knowledge
• Operate on an independent basis with little supervision
• Settle claims within assigned authority
• Maintain contact with attorneys concerning serious claim matters
• Review court decisions, law and coverage interpretations

Senior Claims Specialist – Auto Bodily Injury

• Claims Management: Oversees end-to-end claims process. Responsible for active case management of Life claims. Ensures claims are processed accurately within regulatory and company guidelines. Deliver an exceptional customer experience and ensure that customer commitments and deliverables are achieved. Review and interpret medical records, utilizing resources as appropriate. Complete complex financial calculations specific to claims when applicable. Gain an understanding and working knowledge of the Equitable claim and other applicable systems, policies, procedures, and contracts as well as regulatory and statutory requirements for claim adjudication. Apply contract/policy provisions to ensure accurate eligibility and liability decisions. Demonstrate and apply analytical and critical thinking skills.
• Client and Customer Relationships: Foster strong relationships with clients to understand their needs and ensure high levels of satisfaction. Addresses and resolves any customer challenges or concerns promptly. Communication via telephone, email, and text with employees, employers, attorneys, and others. Provide timely and exceptional customer experience by paying appropriate claims accurately and timely, responding to all inquiries and maintaining expected service and quality standards. Work within a fast-paced environment, with tight deadlines, and demonstrate the ability to balance multiple priorities. Work independently as well as within a team structure. Assist in training and mentoring junior claim examiners on best practices, improving their decision-making skills. Oversee the ongoing management of complex, high-priority or escalated cases and callers.

Senior Group Life Claims Examiner

• 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

• keying, processing health claims in accordance with claims policies and procedures
• able to handle more complex claim with a good understanding of the application of benefit contracts, pricing, processing, policies, procedures, government regs, coordination of benefits, healthcare terminology
• adjust claims
• reviews, analyzes and processes claims/policies related to events to determine extent of company's liability and entitlement
• researches and analyzes claims issues
• responds to inquiries, may involve customer/client contact

Claims Representative II – Health & Dental

• To analyze complex or technically difficult liability claims to determine benefits due.
• To work with high exposure claims involving litigation and rehabilitation.
• To ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements.
• To identify subrogation of claims and negotiate settlements.
• Analyzes and processes complex or technically difficult liability 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.
• Assesses liability and resolves claims within evaluation.
• 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 claims within designated authority level.

Claims Examiner – Liability, GL, BI, Litigation Experience Required

• Streamlined Processing: Ensure claims accuracy and timely submission, minimizing disruptions for patients and practices.
• Issue Resolution: Address rejected or denied claims promptly, resolving challenges with finesse and professionalism.
• Account Integrity: Conduct thorough audits and manage escalation cases, safeguarding the integrity of every account.
• Financial Recovery: Track and recover missing payments efficiently, optimizing revenue streams for our practices.
• Technological Mastery: Utilize cutting-edge platforms like sFax, Adobe, PureCloud, and JIRA with proficiency, enhancing workflow efficiency and collaboration.
• Professional Growth: Take ownership of your development journey, embracing opportunities for advancement and skill enhancement.
• Cross-Functional Collaboration: Foster strong relationships across OrthoFi departments, understanding their functions and enhancing synergy for maximum impact.

Claims Coordinator

• To analyze mid- and higher-level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.
• Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
• Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
• Manages subrogation of claims and negotiates settlements.
• Communicates claim action with claimant and client.
• Ensures claim files are properly documented and claims coding is correct.
• May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
• Maintains professional client relationships.

Claims Adjuster – Workers Compensation, Dedicated Account

• Review, investigate, and resolve transportation claims in accordance with company policies and procedures
• Demonstrate comprehensive knowledge of carrier services, including tracking, reporting, and billing methods
• Utilize effective problem-solving skills to verify potential claims identified by proprietary auditing systems
• Communicate information to carriers clearly, concisely, and in an organized manner
• Meet or exceed company expectations for key performance indicators
• Prioritize daily tasks of claims to be completed using time management skills
• Provide accurate and timely updates of claims information and resolutions in proprietary systems
• Escalate issues to leadership as they arise

Claims Processor

• 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, and damages
• Adjusting and negotiating claims
• Meeting customer needs with appropriate skills
• Identifying fraud potential and how to handle them
• Recognizing parts of a vehicle and property damage

Claims Adjuster Trainee

• Investigates and adjudicates claims within designated authority, ensuring compliance with appropriate statutory laws.
• Verifies coverage, establishes and maintains reserves, secures recorded statements, drafts and processes correspondence, reports and records.
• Obtains additional information as required to determine liability.
• Documents claim files and facilitates processing of claims in collaboration with other departments.
• Assigns outside experts when necessary to assist in investigation and in support of potential recovery.
• Establishes contact with all parties involved in the claim in accordance with ERIE’s expectations.
• Evaluates and negotiates claims, recognizes subrogation opportunities, and initiates action.
• Sets up and/or issues payment using ERIE’s approved payment methods for settlement; or declines payment within designated authority.
• Responds to inquiries from Policyholders, Agents, insurance carriers, claimants, assigned experts and others.
• Learns and maintains knowledge of liability laws for each state.
• Learns and maintains knowledge of motor vehicle codes.
• Learns and maintains knowledge of no fault/medical management/FPB laws for each state, including recognition of bodily injury claims.
• With supervisor guidance, responds to intercompany arbitration applications.
• Files contentions and supporting documents on behalf of the insured/driver.
• Conducts research, attends industry-related training programs and other training sessions to stay current on policy changes, interpretation, or new legislation.
• Provides support for property claims during periods of heavy volume.

Inside Claims Representative

• 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

• Deliver an exceptional customer experience and ensure that customer commitments and deliverables are achieved
• Review and interpret medical records, utilizing resources as appropriate
• Complete financial calculations
• Document objective, clear and technical rationale for all claim determinations

Disability and Leave Management Claims Specialist

• Investigates, evaluates, and resolves property damage and general liability claims
• Conducts or coordinates field inspections, property assessments, and damage estimates for property claims as required
• Prepares coverage position letters, and issues reservation of rights correspondence as appropriate
• Develops and executes resolution strategies with clear file notes reflecting focus, control, and momentum
• Maintains timely diary management and accurate documentation of all claim activity

Senior Claims Examiner, Property

• Investigate, analyze, and determine the extent of company's liability concerning Claims and attempt to effect settlement with claimants.
• Correspond with or interview medical specialists, agents, witnesses, or claimants to compile information.
• Calculate benefit payments and approve payment of Claims within a certain monetary limit.
• Responsible for Claims management of assigned cases within guidelines of published performance standards.
• Opens new Claims, completes three-point contact, and performs needed investigations to determine compensability as well as possible subrogation or apportionment, according to state and/or Zenith’s timeframes and guidelines.
• Follows appropriate procedures for system documentation to preserve data integrity.
• Monitors and maintains accuracy of reserves over the life of the claim; when new information is received re-evaluates and recommends reserves according to Zenith’s standards.
• Creates and executes action plans needed to bring case to closure.
• Completes detailed settlement evaluations and recommends appropriate settlement value, within authority; negotiates claim settlements with injured workers and/or injured workers’ attorneys.
• Maintains regular contact with injured workers, employers and agents to develop positive relationships and establish credibility.
• Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
• Works productively and harmoniously with others on a consistent basis.
• Respond positively to direction and criticism of performance.
• Consistently maintain professional and appropriate demeanor.

Workers' Comp Claims Specialist

• Evaluate dental prior approval requests for North Carolina Medicaid
• Analyze requests, apply Medicaid policy, and ensure accurate and timely determinations
• Use computer systems, claims processing applications, and electronic documentation tools to perform tasks

Healthcare Claims Examiner, Dental Hygienist – NC Dental Hygiene License Required

• 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

• Responsible for handling Management Liability Claims (EPL, D&O, Fiduciary and Crime) for Private and Non-Profit businesses based on Claim Guidelines
• Within authority limit, thoroughly analyze, investigate, negotiate and resolve all levels of severity claims
• Selects, directs and manages defense counsel including approval of budgets
• Develops litigation/file disposition strategy
• Attends mediations, settlement conferences and trials
• Verifies/analyzes applicable coverage for the reported claims
• Follow operational policies and procedures, including compliance, regulatory and performance and customer service standards
• Prepare reports, including Large Loss Reports, to management which accurately reflects loss development, potential/actual financial exposure, coverage issues, claim and recovery strategies
• Establishes 24-hour contact and maintain appropriate contact with all involved stakeholders throughout the life of the claim file
• Identifies and addresses recovery/contribution/SIU opportunities
• Sets accurate/timely loss/expense reserves in compliance with Claim Guidelines
• Drafts correspondence, including but not limited to, coverage letters to stakeholders as required
• Support business partners on an as needed basis on various claim and underwriting related issues and marketing meetings
• Maintains resident/nonresident adjuster licenses as required
• Performs other duties as assigned.

Management Liability Claims Specialist

• Responsible for handling Management Liability Claims (EPL, D&O, Fiduciary and Crime) for Private and Non-Profit businesses based on Claim Guidelines
• Within authority limit, thoroughly analyze, investigate, negotiate and resolve all levels of severity claims
• Selects, directs and manages defense counsel including approval of budgets
• Develops litigation/file disposition strategy.
• Attends mediations, settlement conferences and trials
• Verifies/analyzes applicable coverage for the reported claims
• Follow operational policies and procedures, including compliance, regulatory and performance and customer service standards
• Prepare reports, including Large Loss Reports, to management which accurately reflects loss development, potential/actual financial exposure, coverage issues, claim and recovery strategies
• Establishes 24-hour contact and maintain appropriate contact with all involved stakeholders throughout the life of the claim file
• Identifies and addresses recovery/contribution/SIU opportunities
• Sets accurate/timely loss/expense reserves in compliance with Claim Guidelines.
• Drafts correspondence, including but not limited to, coverage letters to stakeholders as required
• Support business partners on an as needed basis on various claim and underwriting related issues and marketing meetings
• Maintains resident/nonresident adjuster licenses as required
• Performs other duties as assigned

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