Claims Specialist

• 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.
• To identify subrogation of claims and negotiate settlements.

Claims Adjuster – Workers Compensation

• 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

• Manage the claims reporting process for agency clients.
• Report claims to the appropriate carrier and maintain records in the agency management system by documenting claim actions in accordance with established procedures.
• Follow up on claims to obtain the specific adjuster and claim number relevant to the reported loss.
• Notify appropriate parties when a claim is processed with carrier, providing accurate and timely claim information.
• Continuously monitor claims until claims are closed by the insurance carrier.
• Report any potential issues with a claim to the client's Account Manager and Producer, escalating to management as needed.
• Prepare reports by collecting and summarizing information as requested by management.

Commercial Lines Claims Specialist

• Investigates, evaluates, negotiates, and resolves assigned claims
• Handles the most complex claims with minimal manager oversight
• Establishes and maintains positive relationships with customers
• Assists in building business relationships with agents, insureds and partners
• Develops and mentors other associates
• Assists leadership in training and resources development
• Maintains proper reserving through proactive investigation
• Assists other departments with investigations as required

Claims Representative, Casualty Large Loss, Auto Injury

• Works closely with veterinary hospitals, and policyholders to evaluate and review a pet’s medical history to determine a baseline of health.
• Investigates and processes assigned insurance claims, verifies coverage, and compensation amounts, per insurance policy.
• Updates Explanation of Benefits (EOB), pays and closes claim.
• May order medical records from providers.
• May communicate with clients and providers during treatment.
• Performs other duties and responsibilities as assigned.

Claims Adjuster – Associate

• Ensure compliance with established claim handling guidelines regarding coverage, investigation, liability, damages, evaluation, and resolution.
• Provide oversight on claims portfolios within the primary casualty book.
• Maintain direct contact with insureds, agents, and brokers.
• Provide oversight on claims portfolios handled by TPAs within the excess casualty book.
• Engage in rigorous ALAE control and management, by competently selecting, instructing, and managing 3rd party vendors, as appropriate.
• Gather and analyse information necessary to make an accurate evaluation of the claim by delivering effective resolution of claims, make decision within established authority levels and identifying settlement issues.
• Establish reserves pursuant to established reserving protocols and reserve authority procedures.
• Successfully and proactively resolve complex and/or high exposure claims, promptly limiting exposure to the Company.
• Substantial involvement in mediation negotiations will be required.
• Adhere to the Panel Counsel Program and all Litigation Management Guidelines.
• Meet all Reporting Requirements by completing reports timely and accurately, including Large Loss Reports, etc.
• Liaise and attend meetings with the underwriting team regarding claim trends and other areas of interest.
• Work with external customers to address questions, resolve problems and maintain rapport.
• Occasional domestic travel may be required to attend mediations and/or trials.
• Undertaking general office administrative duties as and when required.
• Proactively expanding and maintaining awareness of the current market/industry and attend continuing educations programs when available.
• In addition to the above key responsibilities, you may be required to undertake other duties from time to time as the Company may reasonably require.

Claims Examiner – Commercial Healthcare

• 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.

Property Claims Examiner II – Wind/Hail

• Manage lost time and medical only Workers' Compensation claims.
• Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims.
• Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines.
• Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.
• Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed.
• Utilize proactive reserving behaviors to ensure adequate case reserves.
• Consults with assigned claim director, return to work specialists, nurse case managers, and internal/external medical professionals.
• Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs.

Lost Time Claims Adjuster – Workers' Compensation

• Conduct field based investigations by visiting policyholders’ homes
• Use claims handling software, a company car and laptop
• Represents the Company and must conduct oneself as a member of Management
• Use strong customer service skills to negotiate with policyholders

Field Property Claims Adjuster

• Processes and review subrogation claims across all lines of business and all jurisdictions with a mid-level caseload and complexity.
• Processes payment checks received in accordance with company check processing guidelines.
• Processes regular recovery files.
• Coordinates with collection agencies and adheres to company standards and industry best practices within the Claims Recovery Team.
• Responsible for assigned inventory of mid-level subrogation files with recovery.
• Maintains a diary, on cadence, aligned to department service expectations and schedules follow up to ensure timely payment.
• Processes recoveries into various claims systems to ensure the recovery dollars are applied to appropriate claims file.
• Analyzes and processes invoices for various internal/external vendors involved in recoveries including attorneys, collections, and independent investigators.
• Works with collections agencies when appropriate to collect from at-fault parties and records details in claims file.
• Notifies appropriate parties of subrogation lien.
• Uses technology and resources as needed to complete investigation.
• Responds to clients' questions timely and professionally.
• Prepares various type status reports for clients.

Recovery Claims Representative, License Required

• To analyze complex or technically difficult workers compensation claims to determine benefits due;
• to work with high exposure claims involving litigation and rehabilitation;
• and to ensure ongoing adjudication of claims within company standards and industry best practices or client specific requirements.
• Analyzes and processes complex or technically difficult claims by investigating and gathering information to assist employer in determining their position on the claim;
• manages claims through well-developed action plans to an appropriate and timely resolution.
• Works to move claim towards appropriate claim closure which may include referral for settlement evaluation.
• Monitors reserve adequacy throughout the life of the claim if applicable.
• Monitors and reviews benefits due and payment calculations ensuring accuracy.
• Prepares necessary state filings within statutory limits.
• Follows best practice standards in contested claims including outside legal representation.
• 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.
• Participates in claim recoveries including, but not limited to: subrogation, Second Injury Fund recoveries, and Social Security offsets.
• Communicates claim action/processing with appropriate parties including, but not limited to: claimant, client, state agency, managed care organization and appropriate medical contact.
• Ensures claims files are properly documented and claims coding is correct.
• Maintains professional client relationships.
• Coordinates actuarial/settlement issues impacting employers with rate and settlement departments.
• Assesses policy level status of clients; works in coordination with clients' service expectations and assigned service personnel.

Claims Examiner – Workers Comp

• To analyze and process low to mid-level auto and transportation claims.
• Processes auto property damage and lower level injury 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).

Claims Specialist jobs in Ohio

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