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 Examiner Manager

• 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

• To analyze and process complex bodily injury auto and commercial transportation claims by reviewing coverage, completing investigations, determining liability and evaluating the scope of damages.
• Processes complex auto commercial and personal line claims, including bodily injury and ensures claim files are properly documented and coded correctly.
• Responsible for litigation process on litigated claims.
• Coordinates vendor management, including the use of independent adjusters to assist the investigation of claims.
• Reports large claims to excess carrier(s).
• Develops and maintains action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution.
• Identifies and pursues subrogation and risk transfer opportunities; secures and disposes of salvage.
• Communicates claim action/processing with insured, client, and agent or broker when appropriate.
• Performs other duties as assigned. Supports the organization's quality program(s).
• Travels as required.

Claims Examiner – Auto, Bodily Injury

• Investigate, analyze, and determine the extent of liability concerning first party homeowner property losses and damages.
• Effectively communicate and negotiate with policyholders, agents, public adjusters, attorneys, and service providers via phone, email, and internal systems to accurately document claim details.
• Successfully manage a pending claim load at varying stages of the claims process.
• Interpret and apply the details of an insurance policy to ensure the accuracy of payments and claims declinations.
• Interpret and apply computer generated loss estimates, engineer’s reports, and construction terminology.
• Update and maintain comprehensive claim handling notations in our electronic claims management system and other related applications.
• Mentor our mid and associate level claims representatives.

Complex Claims Representative

• 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

• Investigate, analyze, and determine the extent of liability concerning first party homeowner property large losses and damages of $100K+.
• Negotiate settlements and make payments within scope of authority, settling claims timely, and in the most cost-effective manner.
• Effectively communicate with policyholders, agents, and service providers via phone, email, and internal systems to accurately document claim details.
• Effectively manage loss and expense reserves to ensure accurate and timely reserving practices on all large loss claim exposures.
• Create and maintain comprehensive claim handling documentation in the electronic claims management system and related applications including the completion and escalation of Large Loss Reports (LLR’s).
• Ability to successfully manage a pending claim volume at varying stages in the claims process.
• Interpret and apply the details of an insurance policy to ensure the accuracy of payments and claims declinations.
• Ability to understand, computer generated loss estimates and construction terminology.
• Update and maintain comprehensive claim handling notations in our electronic claims management system and other related applications.

Claims Specialist – Large Loss

• Reviews and adjudicates complex or specialty claims.
• Determines whether to return, deny or pay claims following organizational policies and procedures.
• Assists in training or mentoring new staff members.
• Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines.
• Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes.
• Verifies that claims have been keyed correctly.
• Ensures that claims are processing according to established quality and production standards.
• Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
• Researches and resolves claims edits and deferrals.
• Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas.
• Responds to routine correspondence and completes spreadsheet if applicable.

Claims Processor II

• handles entry-level insurance claims under close supervision
• investigates, evaluates, and settles entry-level insurance claims
• studies insurance policies, endorsements, and forms to develop foundational knowledge on Company insurance products
• learns and complies with Company claim handling procedures
• develops entry-level claim negotiation and settlement skills
• builds skills to effectively serve the needs of agents, insureds, and others
• meets and communicates with claimants, legal counsel, and third-parties
• develops specialized skills including estimating and use of designated computer-based programs for loss adjustment
• studies, obtains, and maintains an adjuster’s license(s), if required by statute within the timeline established by the Company or legal requirements

Claims Representative

• Responsible for the thorough, fair, objective, and timely adjudication of voluntary benefits claims
• Provide excellent customer service and interact on a regular basis with employees, employers, health care providers and other specialized internal resources
• Develop an understanding and working knowledge of Voluntary Benefits for Unum and Colonial Life
• Develop skill set to determine appropriate risk management strategies through analyzing and applying technical and complex contractual knowledge
• Produce objective, clear documentation and technical rationale for all claim determinations
• Partner and coordinate file strategies utilizing specialized resources including nurses, physicians, vocational rehabilitation and assessing medical documentation
• Ensure a timely and well communicated transfer process when transitioning integrated claims across lines of business

Associate VB Claims Specialist

• Determine compensability and/or coverage issues for loss time workers' compensation claims.
• Effectively manage a caseload of loss time claims from numerous jurisdictions.
• Negotiate and direct settlements under management's review.
• Gather medical and factual evidence to determine compensability.
• Direct outside investigation and handle litigation files within given authority.
• Coordinate and maintain contact with claimants and/or their attorneys, outside investigators, and rehabilitation personnel as well as routine contact with insureds, account liaisons and medical providers.

Workers' Compensation Claims Representative

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Claims Specialist II

• Manages an inventory of claims to evaluate compensability/liability
• Conducts claim investigations to confirm coverage and to determine liability, compensability and damages
• Determines and may negotiate appropriate claim settlements/reserves within prescribed authority
• May attend arbitrations, mediations, depositions, or trials
• Conveys routine to moderately complex information regarding coverage and settlements to insureds, claimants, and external partners
• May authorize 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.

Claims Representative – Medical Only

• Independently investigates, evaluates, and negotiates the resolution of assigned claims within approved authority
• Responsible for making recommendations for claim outcomes on claims exceeding level of authority
• Conduct investigations of assigned claims in adherence with corporate timeliness and quality performance standards
• 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 as required
• Direct the litigation process and work with attorneys to establish defense strategy and case legal budget
• Negotiate settlements with opposing counsel
• Evaluate specials, damages, and/or extent of disability, and negotiate settlement with individual claimants and/or attorneys
• Review independent adjustor's reports and handle claim outcomes.

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