Claims Specialist

• 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

• Manage a desk and caseload of workers’ compensation claims in an efficient and professional manner
• Investigate claims thoroughly, including coverage, liability, and exposure analysis
• Evaluate claim exposure and maintain accurate and timely reserves
• Manage litigation activity and coordinate with defense counsel as needed
• Evaluate claims for settlement and negotiate resolutions with claimants and attorneys
• Monitor and manage medical treatment activity and claim progression
• Maintain accurate, timely, and organized claim documentation within the claims system
• Ensure claim payments are processed accurately and timely
• Support timely and compliant claim resolution strategies
• Maintain communication with employers, injured workers, attorneys, medical providers, and clients throughout the claims process
• Participate in required training and maintain knowledge of assigned state workers’ compensation statutes
• Perform additional duties and projects as assigned

Workers Compensation Claims Examiner

• Gain knowledge to verify coverage, compensability, and reasonable payments by thoroughly reviewing the policy, reviewing accident details, and other pertinent information related to the claim.
• Develop investigative claims skills by taking and reviewing recorded statements from involved parties and witnesses, reviewing police reports, and other pertinent evidence.
• Build knowledge to evaluate claims exposure appropriately, establishing timely reserves.
• Comply with industry regulations, legal requirements, and internal company policies through thorough documentation of all decisions, correspondence, and discussions that occur throughout the life cycle of the claim.
• Support customers with empathy and understanding, assisting them through difficult situations and effectively communicating the claims process, ongoing claim status, and decisions, including the reasoning behind them.
• Ability to obtain and maintain state licensing requirements.

Claims Representative, Entry Level – Fast Track

• 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

• Manage a caseload of transportation bodily injury claims, including litigated and non-litigated exposures
• Investigate, evaluate, negotiate, and resolve trucking and transportation related claims in accordance with company guidelines and regulatory requirements
• Handle claims involving long-haul trucking, semi-trucks, and commercial transportation exposures
• Review coverage, assess liability, and determine appropriate claim resolution strategies
• Coordinate with defense counsel and support litigation management activities as needed
• Maintain ownership of bodily injury claims and associated property damage exposures throughout the life of the claim
• Maintain accurate and timely documentation within the claims management system
• Communicate professionally with insureds, claimants, attorneys, vendors, and internal stakeholders
• Ensure compliance with applicable state regulations and company policies
• Negotiate settlements and support timely claim resolution strategies
• Mentor less experienced team members and assist with claims handling guidance when appropriate
• Perform additional duties and projects as assigned

Senior Transportation Claims Adjuster

• 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

• Gain knowledge to verify coverage, compensability, and reasonable payments by thoroughly reviewing the policy, reviewing accident details, and other pertinent information related to the claim
• Develop investigative claims skills by taking and reviewing recorded statements from involved parties and witnesses, reviewing police reports, and other pertinent evidence
• Build knowledge to evaluate claims exposure appropriately, establishing timely reserves
• Comply with industry regulations, legal requirements, and internal company policies through thorough documentation of all decisions, correspondence, and discussions that occur throughout the life cycle of the claim
• Support customers with empathy and understanding, assisting them through difficult situations and effectively communicating the claims process, ongoing claim status, and decisions, including the reasoning behind them

Claims Representative – Entry Level

• 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

• 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

• Analyze reported lower-level workers compensation claims to determine benefits due.
• Ensure ongoing adjudication of claims within company standards and industry best practices.
• Handle lower-level liability and/or physical damage claims under close supervision.
• Support other claims representatives, examiners, and leads with larger or more complex claims as necessary.
• Process general liability claims determining compensability and benefits due; monitor reserve accuracy, and file necessary documentation with state agency.
• Communicate claim action/processing with claimant, client, and appropriate medical contact.
• Ensure claim files are properly documented and claims coding is correct.
• May process routine payments and prescriptions and status reports for lifetime medical claims and/or defined period medical claims.
• Maintain professional client relationships.

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Senior Claims Adjuster, Large Loss

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Workers' Compensation Claims Representative

Claims Specialist II

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Claims Associate – Liability