Claims Specialist

• Review, analyze, and process pharmacy claims with accuracy, timeliness, and adherence to company and regulatory standards.
• Identify discrepancies, investigate claim issues, and determine appropriate resolutions.
• Communicate effectively with pharmacies, providers, and internal teams to clarify information and resolve errors.
• Support audits and quality reviews by maintaining detailed, accurate claim documentation.
• Identify trends and share insights that can improve claim accuracy and efficiency.
• Uphold confidentiality and compliance with HIPAA and corporate policy standards.

Pharmacy Claims Representative

• Provide prompt, courteous, and high-quality customer service to all policyholders and claimants by answering customer calls, texts, and/or emails in a timely and accurate manner.
• Gather necessary information from customers to initiate the claim and explain policy, coverage, and educate them on the claims process and next steps.
• Manage an inventory of claims, establish initial reserves for all potential exposures, and adjust as appropriate throughout the claim.
• Work with the APD team on the handling of property damage claims.
• Recognize recovery opportunities with regard to subrogation and salvage, as well as total loss.
• Ensure compliance with specific state regulations, policy provisions, and standard operating procedures.
• Negotiate appropriate settlements with claimants, insureds, and attorneys within approved payment authority.
• Provide input to continuously develop claims guidelines, best practices, and process improvements.
• Know the claims inside and out and ensure outside investigative service providers, including independent appraisers and defense counsel, are guided based on what we need to move the file to a quick and appropriate resolution.
• All the while keeping our clients updated where needed.
• Engage in learning opportunities to build knowledge of claims statutes, recent/updated court decisions impacting the claims function, current internal guidelines, and policy changes and modifications.

Claims Adjuster, Trucking BI

• Develop and execute the vision of the General Motors Insurance quality improvement function within the claims department, continuously improving, and enhancing this function in accordance with claims best practices and regulatory requirements
• Create and maintain file audit dashboards to educate Claims leadership on trends, performance, and opportunities for improvement
• Develop and implement automated systematic claims handling quality file review and audit processes
• Collaborate with claims leaders to develop and implement policies, standards, processes, controls, and related documentation of best practices, guidelines, and workflows to ensure a center of excellence within Claim Quality Improvement
• Develop and implement quality and compliance reviews of General Motors Insurance Company claims to ensure quality and appropriate service results, to drive best in class claims handling
• Develop meaningful, updated audit forms calibrated to claims best practices and current regulatory requirements, analyze audit results, reporting on the results, and developing post-audit management action plans to drive continuous improvement
• Monitor, coordinate, track, measure, and report to internal stakeholders trends, issues, opportunities, and analysis on file quality data
• Collaborate with Claims leadership and related internal stakeholders on training initiatives, job aids, guidelines to continuously improve claims handling quality and execution in support of team and individual professional growth and development
• Bring a solid understanding of compliance issues and regulatory environment in all project development and implementation.
• Build and maintain key relationships with internal stakeholders (e.g., Peers, Operations, Learning & Development, various executive management leaders) and external stakeholders (e.g., auditors and vendors)

Claims Quality Improvement Analyst

• Reviewing and processing claims
• Identifying irregularities and reviewing for accuracy
• Complying with policy provisions and appropriate state and federal laws
• Managing high volume of semi-routine claims and phone calls
• Explaining basic contract definitions to insureds verbally and in writing
• Processing claim operational activities including tax reporting, journal vouchers, and overpayments

Senior Claims Analyst

• Provides advanced technical review of all types of claims in accordance with Company guidelines
• Performs technical review and analysis of all types of claims to ensure accuracy and adherence to prescribed procedures and plan guidelines
• Coordinates appeals through research and documentation; generates denial or approval letters
• Coordinates predetermination reviews and performs analysis to determine benefit allowance and benefit category
• Processes refunds, voids, and overpayments, including related claim adjustments
• Processes time loss claims and communicates with local union offices, medical service providers, employers, and members
• Reviews and interprets new benefit plans or plan changes

Claims Technical Review Specialist

• Communicating with claimants, employers and various medical professionals through phone and e-mail to gather information regarding Voluntary Claims.
• Leveraging knowledge of coverage, contract provisions, eligibility & benefits as well as other appropriate resources to review submitted claim information for payment.
• Applying core knowledge of voluntary insurance products and claims processes to review questions/concerns and provide specific information to internal/external stakeholders.
• Making routine & non-routine decisions under close supervision, applying limited discretion within role.

Voluntary Claims Specialist

• Proactively manages assigned claims caseload comprised of complex damages that require commensurate knowledge and understanding of claims coverage including potential legal liability.
• Partners with vendors and internal business partners to facilitate complex claims resolution.
• May also involve external regulatory coordination to ensure appropriate documentation and compliance.
• Investigates claim damages by conducting research from various sources, including the insured, third parties, and external resources.
• May identify and resolve potential discrepancies and identifies subrogation potential resulting from unusual characteristics.
• Identifies coverage concerns, reviews prior loss history, determines and creates Special Investigation Unit (SIU) referrals, when appropriate.
• Determines coverage through analyzing information involving complex policy terms and contingencies.
• Determines and negotiates complex claims settlement within authority limits.
• Develops recommendations and collaborates with management for determining settlement amounts outside of authority limits and accurately manages claims outcomes.
• Maintains accurate, thorough, and current claim file documentation throughout the claims process.
• Advance knowledge of estimating technology platforms and virtual inspection tools.
• Utilizes platforms and tools to prepare claims estimates to manage complex property insurance claims.
• Supports workload surges and catastrophe (CAT) response operations as needed, including mandatory on-call dates and potential evening, weekend, and/or holiday work outside normal work hours.
• May be assigned CAT deployment travel with minimal notice during designated CATs.
• Works various types of claims, including ones of higher complexity, and may be assigned additional work outside normal duties as needed.
• Works independently solving complex problems with minimal guidance; acts as a resource for colleagues with less experience.
• Adjusts complex claims with attorney involvement.
• Recognizes and addresses jurisdictional challenges such as applicable legislation and construction considerations.
• May require travel to resolve claims, attend training, and conduct in-person inspections.
• Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.

Property Claims Adjuster Specialist – Desk

• Adjusts attorney-involved moderately complex bodily injury claims with demonstrable injuries (e.g. torn meniscus, broken bones, disc herniations), as well as all auto physical damage associated with those claims
• Identifies, confirms, and makes coverage decisions on moderately complex bodily injury claims
• Investigates loss details, determines legal liability, evaluates, negotiates, and arrives at claim settlement within appropriate authority guidelines
• Clearly documents thought process, investigation, evaluation, negotiation, and settlement decisions
• Prioritizes and manages assigned claims workload to keep members and other involved parties informed, provides timely claims status updates
• Collaborates and supports team members to resolve issues and identify appropriate matters for escalation
• Partners and/or directs vendors and internal business partners to facilitate timely claims resolution
• Supports workload surges and/or Catastrophe Operations as needed
• May act as an informal resource for team members with less experience

Senior Injury Claims Adjuster

• Identify and obtain statements from insureds, vendors and witnesses.
• Conduct phone and/or field investigations to determine coverage and damages and differentiate between allegations and facts in each loss.
• Communicate and interact with a variety of individuals.
• Explain benefits, coverages, and claims process either verbally or in writing in compliance with regulatory and statutory requirements.
• Recognize and appropriately address moderate complexity coverage issues.
• Evaluate and determine claim values upon receipt and assessment of property damage data.
• Negotiate within settlement authority with insureds to resolve first claims.
• Update database production reports, and document and update claim files via company systems, i.e. CACS, HUON, HOC, GUIDEWIRE, etc.
• Control expenses for areas of responsibility.
• Verify and interpret / resolve coverage by gathering necessary information to ensure policy applicability.
• Objectively discern and address issues that may be questioned in audit.
• Coordinate with internal and external departments as required.
• May attend and participate in legal proceedings.
• Respond quickly and effectively to customer needs and problems.

Senior Property Adjuster

• Responsible for the resolution of moderate to high complexity ocean marine bodily injury and property damage claims
• Handle claims from coverage enquiry through legal liability assessment and quantum analysis
• Communicating developments and outcomes to all internal and external stakeholders
• Training and providing referral support for other team members
• Analyze coverage and communicates coverage positions
• Prepare coverage position letters
• Conduct investigations into loss facts and damages
• Initiating timely contact to appropriate parties throughout the claim's lifecycle
• Evaluating information on coverage, liability, and damage
• Negotiate and settle claims directly or indirectly
• Present at roundtables to senior claims leaders and underwriters

Senior Claims Examiner, Ocean Marine Claims

• 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

• Conduct field inspections and related tasks
• Read maps and aerial photos, measure fields, and discuss findings with farmers
• Convey complex regulations and interpretations to claimants and agents
• Perform fact finding regarding crop damage and transmit loss information
• Complete claim reviews and audits on lower-level adjusters as assigned
• Ensure compliance with regulatory and company policies
• Contribute to team goals

Crop Claims Field Adjuster I/II/Specialist

• Analyze complex coverage issues, conduct detailed investigations, and evaluate damages and liability to determine the validity of moderate to highly complex commercial property and casualty claims
• Handle high-exposure property losses, including large commercial building, business personal property, business interruption, inland marine, equipment breakdown, crime, and bond claims
• Investigate and evaluate third-party casualty claims, including general liability, premises liability, product liability, contractual liability, and bodily injury/property damage claims
• Formulate and issue formal coverage position letters and liability determinations based on policy language, facts, and applicable legal principles
• Conduct comprehensive investigations, including interviews of insureds, claimants, witnesses, and other involved parties to determine coverage, liability, causation, and damages
• Coordinate and manage field investigations, site inspections, scene examinations, and independent adjuster assignments as necessary
• Identify, retain, and manage experts including engineers, building consultants, forensic accountants, cause-and-origin specialists, medical professionals, accident reconstructionists, and defense counsel to support claim resolution
• Review and analyze repair estimates, contractor bids, engineering reports, medical records, litigation documents, and expert evaluations to determine the extent of damages, liability exposure, and appropriate claim disposition
• Assess comparative negligence, liability defenses, subrogation opportunities, and risk-transfer provisions where applicable
• Establish, monitor, and recommend appropriate reserves based on claim complexity, damages, liability exposure, and settlement potential
• Develop and execute claim resolution strategies for large-loss and high-severity claims, including those with significant litigation potential
• Collaborate with defense counsel and litigation management teams on litigated matters, monitoring case strategy, budgets, exposure assessments, and settlement opportunities
• Prepare detailed large loss and management reports summarizing coverage positions, liability assessments, damage evaluations, reserve adequacy, and settlement recommendations
• Present claim evaluations and settlement recommendations to management for claims exceeding assigned authority limits
• Negotiate fair and timely settlements with insureds, claimants, attorneys, contractors, and other parties within delegated authority
• Communicate effectively with insureds, agents, brokers, claimants, attorneys, and internal business partners to provide superior customer service and ensure transparency throughout the claims process
• Manage a high-volume and complex caseload while maintaining proactive diary management and meeting all regulatory and company service standards
• Maintain complete, accurate, and organized claim files in accordance with company policies, best practices, audit standards, and regulatory requirements
• Identify trends, emerging risks, and exposure concerns and provide recommendations to management regarding claim handling strategies and risk mitigation opportunities

Senior Claims Adjuster, Property and Casualty

• Processing new age claims according to guidelines
• Keeping claims under 30 days along with aging reports
• Submitting service requests for claim updates or needs
• Participating in team activities and assisting with processing 175-200 claims per day
• Logging claims for claims escalations and helping others reach team goals
• Researching resubmitted or corrected claims and pend appropriately
• Referring fee schedule, vendor contract, plan problems, or concerns to manager or senior processors
• Processing CMS 1500 and/or UB04 claims

Claims Processor

• Handle entry-level insurance claims under close supervision through the life-cycle of a claim including but not limited to: investigation, evaluation, and claim resolution
• Provide service to agents, insureds, and others to ensure claims resolve accurately and timely
• Participate in training and development completion of the Company’s claims training program for the assigned line of insurance
• Investigate, evaluate, and settle entry-level insurance claims
• Study insurance policies, endorsements, and forms to develop foundational knowledge on Company insurance products
• Learn and comply with Company claim handling procedures
• Develop entry-level claim negotiation and settlement skills
• Build skills to effectively serve the needs of agents, insureds, and others
• Meet and communicate with claimants, legal counsel, and third-parties
• Develop specialized skills including but not limited to, estimating and use of designated computer-based programs for loss adjustment
• Study, obtain, and maintain an adjuster’s license(s), if required by statute within the timeline established by the Company or legal requirements.

Auto Claims Representative

• Extensive policy document and legal contract interpretation
• Ability to analyze and identify coverage and related coverage issues
• Leverage a working knowledge of insurance contracts, Unfair Claims Settlement Practices, insurance codes, civil codes, vehicle codes, arbitration rules and regulations, tort law, claims best practices handling and management as part of your ongoing adjudication of claims
• Manage, investigate, and resolve claims within prescribed authority levels
• Recommend ultimate resolution on assigned cases in excess of authority to claims management
• Rely on a deep background of litigation handling experience in both General Liability and Casualty files to resolve claims
• Consistently drive litigation, attend mediations, trials, and other alternative dispute resolution avenues
• Communicate with policyholders, witnesses, and claimants in order to gather information regarding claims, refer tasks to auxiliary resources as necessary, and advise as to the proper course of action
• Preemptively communicate and respond to various written (email, SMS, fax, mail) and telephone inquiries, including status reports
• Present file materials for authority and roundtables
• Work with nurses, doctors, and attorneys on file reviews
• Comply with all statutory and regulatory requirements of all applicable jurisdiction
• Meet detailed quality assurance standards and meet set goals for performance
• Set and revise case reserves in accordance with the reserving policy
• Identify potentially suspicious claims and refer to SIU; identify opportunities for third-party subrogation
• Be accountable for the security of the financial processing of claims, as well as security information contained in claims files
• Work with, and provide claim-specific guidance to, independent field adjusters
• Partner closely with internal teams and advise leadership of key claim activities and exposures

• Handle complex cases involving true Bad Faith claims with adverse and identified coverage/claims handling issues.
• Manage documented cases of daycare abuse/molestation, ensuring thorough investigation and resolution.
• Handle fatality cases with coverage issues, providing expert analysis and resolution.
• Manage construction defect cases, specifically focusing on complex ones involving multiple parties and intricate contractual issues.
• Centralize Declaratory Relief Actions by taking charge of coverage files and coordinating with relevant parties.
• Handle severe injury cases with complex issues, including coverage, liability, or damages concerns.
• Evaluate policy limit exposures, ensuring a true policy limit exposure exists and the potential for extra-contractual exposure is real.
• Address problematic claims that require dedicated attention to achieve resolution.

Claims Litigation Specialist

• Investigate and manage New York PIP/No-Fault claims from inception through closure.
• Review medical documentation, treatment plans, wage loss claims, and related expenses.
• Evaluate claim exposure and establish appropriate reserves.
• Coordinate with medical providers, attorneys, insureds, claimants, and vendors.
• Identify and address potential fraud indicators.
• Ensure compliance with New York No-Fault regulations, statutory timelines, and reporting requirements.
• Maintain accurate and timely claim documentation.
• Deliver exceptional customer service while effectively managing claim outcomes.

PIP Claims Adjuster

• Review, analyze, and process complex self-funded medical claims from start to finish.
• Utilize the WLT system daily to adjudicate claims, ensuring all coding, billing, and pricing rules are applied correctly.
• Verify patient eligibility, benefit limits, and plan coverage exclusions based on specific self-funded plan documents.
• Identify and investigate claims requiring additional information, such as coordination of benefits (COB), subrogation, or medical necessity reviews.
• Maintain strict compliance with all federal and state regulations, including HIPAA and ERISA guidelines.
• Meet or exceed established quality accuracy and production turnaround standards.

Medical Claims Examiner

• Investigate claims issues and provide information to damagers including, but not limited to, homeowners and contractors.
• Negotiate settlements with damagers and insurance companies as applicable.
• Review claim information and request/research additional reference material to complete the claim record.
• Determine damager liability by obtaining and reviewing evidence which includes, but is not limited to, physical location information, photographs, reports, locate tickets, permit records, internet research and contact with damagers.
• Dispute resolution and responds to damager objections.
• Provide detailed data entry into customized claims systems.
• Track fees, close and open claims, and other claims information.
• Skip tracing as necessary; utilizing internet resources.

Claims Specialist jobs in United States

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