Claims Specialist

• 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

• The Claims Adjuster is responsible for managing workers compensation claims
• Ensure ongoing adjudication of claims within company standards
• Comply with statutory and regulatory requirements
• Ensure timely claim determinations and payments
• Manage legal aspects of the claim and direct attorneys as needed
• Coordinate assignments with claims assistants

Claims Adjuster

• 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

• Manages mid to complex Auto and/or General Liability claims, including bodily injury and property damage
• Handles litigated files and works with delegated authority
• Receives claims, confirms policy coverage and acknowledgment of the claim
• Determines validity and compensability of the claim
• Investigates claims and handles Auto and/or General Liability claims
• Establishes reserves and authorizes payments within reserving authority limits
• Communicates claim status with the customer, claimant, and client
• Adheres to client and carrier guidelines and participates in claims review as needed
• Collaborates with team members on more complex or problematic claims as necessary
• Additional duties as assigned

Senior Liability Claims Specialist

• Manages an inventory of claims to evaluate compensability/liability
• Plans and conducts claim investigations to confirm coverage and to determine liability, compensability and damages
• Determines and negotiates appropriate claim settlements/reserves within prescribed authority
• May attend arbitrations, mediations, depositions, or trials
• Conveys moderately complex information regarding coverage and settlements to insureds, claimants, and external partners
• Authorizes payments in accordance with assigned authority limit and ensures payments are made in a timely manner
• Maintains accurate and detailed claim files, including all correspondence, reports, and settlement agreements
• Performs other duties as assigned.

Senior Claims Specialist

• Reviews and processes Wellness and Hospital Indemnity insurance claims
• Determines the nature and validity of claims by reviewing policy status and patient eligibility
• Provides prompt customer service to policy holders, providers, and other internal company entities regarding claims
• Documents phone calls in the system and follows up on issues if needed
• Contacts insured or other appropriate persons to verify the accuracy and completeness of information on claims forms
• Performs other related duties as required

• 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

• Assemble facts, determine coverage, evaluate the amount of loss
• Analyze legal liability, make payments in accordance with coverage, damage and liability determination
• Study insurance policies, endorsements, and forms to develop an understanding of insurance coverage
• Follow claims handling procedures and participate in claim negotiations and settlements
• Deliver a high level of customer service to our agents, insureds, and others
• Devise alternative approaches to provide appropriate service, dependent upon the circumstances
• Meet with people involved with claims, sometimes outside of our office environment
• Handle investigations by telephone, email, mail, and on-site investigations
• Maintain appropriate adjuster’s license(s), if required by statute in the jurisdiction employed
• Handle complex and unusual exposure claims effectively through on-site investigations and through participation in mediations, settlement conferences, and trials
• Handle confidential information according to Company standards and in accordance with any applicable law, regulation, or rule
• Assist in the evaluation and selection of outside counsel
• Maintain punctual attendance according to an assigned work schedule at a Company approved work location.

Bodily Injury Claims Specialist

• Independently investigates, evaluates, and negotiates the resolution of assigned claims
• Conduct investigations of assigned claims in adherence with corporate timeliness and quality performance standards
• Manage caseload to ensure proactive disability, medical management and timely response to treatment recommendations
• Document activities, case action plans, settlements evaluations and requests for authorizations in the claim notes
• Provide management and internal and external customers with documentation to support recommendations and claim status
• Direct litigation process and work with attorneys to establish defense strategy and case legal budget
• Negotiate settlements directly with claimants or opposing counsel.
• Evaluate specials, damages, and/or extent of disability and negotiate settlements with individuals and/or attorneys.

Senior Claims Adjuster – Workers Compensation

• reviews and processes Wellness and Hospital Indemnity insurance claims based on information submitted by policy holders
• determines the nature and validity of claims by reviewing policy status, patient eligibility, and supporting medical and other documentation
• keys claims data while interpreting coding and medical terminology in relation to diagnoses and procedures
• uses multiple core administration databases, systems and subsystems to process and transmit claims for payment or further investigation
• provides prompt customer service to policy holders, providers and other internal company entities regarding claims
• documents phone calls in the system and follows-up on issues if needed
• contacts insured or other appropriate persons to verify the accuracy and completeness of information on claims forms and related documents
• responds to inquiries from policy holders, providers, agents regarding claim status and policy provisions
• provides back-up coverage for other teams as required
• maintains databases and prepares and extracts information using software systems
• performs various clerical duties as assigned, such as filing, photocopying, typing, maintaining databases and preparing and extracting information using software systems

• Conduct initial intake and review of affirmative claims cases and related documentation
• Request and obtain police reports, accident reports, medical records, insurance information, and other supporting documentation
• Identify potential insurance carriers and gather information necessary to support claim development
• Communicate professionally with claimants, insurance representatives, medical providers, attorneys, and government personnel
• Perform basic legal and insurance research utilizing available resources such as LexisNexis, Westlaw, and public databases
• Draft initial Notices of Claim, standard demand letters, and routine correspondence for supervisory review
• Maintain accurate electronic case files within the Affirmative Claims Management Program (ACMP) or similar claims management systems

Claims Examiner I

• Conduct initial intake and review of affirmative claims cases and related documentation.
• Request and obtain police reports, accident reports, medical records, insurance information, and other supporting documentation.
• Identify potential insurance carriers and gather information necessary to support claim development.
• Communicate professionally with claimants, insurance representatives, medical providers, attorneys, and government personnel.
• Draft initial Notices of Claim, standard demand letters, and routine correspondence for supervisory review.
• Maintain accurate electronic case files within the Affirmative Claims Management Program (ACMP) or similar claims management systems.

Claims Specialist jobs in South Carolina

See all jobs on JobTailor

Associate Claims Clinical, Care Advocacy

Claims Adjuster

Claims Representative, Casualty Large Loss, Auto Injury

Senior Liability Claims Specialist

Senior Claims Specialist

Claims Specialist

Property Claims Examiner II – Wind/Hail

Lost Time Claims Adjuster – Workers' Compensation

Bodily Injury Claims Specialist

Senior Claims Adjuster – Workers Compensation

Claims Specialist

Claims Examiner I

Claims Examiner Manager