Claims Specialist

• Conduct both virtual and on-site investigations by visiting policyholders’ residences to assess property damage, determine liability, evaluate the extent of loss, and negotiate fair settlements.
• Use claims handling software, a company car, and a laptop to determine claims-related damage and write estimates in a paperless environment.
• Evaluate and report on potential subrogation opportunities.
• Reports incidents involving theft, fraud, or arson to appropriate state and industry agencies.
• Perform duties independently, with work directly impacting management outcomes.
• Acts as a company representative in public interactions, maintaining a professional demeanor consistent with management standards.
• Engages regularly with a variety of stakeholders, including policyholders, claimants, agents, witnesses, contractors, law enforcement, fraud and arson investigators, attorneys, medical professionals, and other relevant parties.
• Use strong customer service skills to negotiate with policyholders to settle the claim.
• Performs additional duties as assigned.
• Promotes safety at all times and complies with safety/ergonomic standards as outlined in relevant company published manuals.
• Employees assigned to the Catastrophe team will be required to travel away from their residence for a specified period of time, usually consisting of 23 days.

Field Property Claims Adjuster

• 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;
• and to identify subrogation of claims and negotiate settlements.
• Manage workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
• Develop and manage workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
• Manages subrogation of claims and negotiates settlements.
• Communicates claim action with claimant and client.
• Ensures claim files are properly documented and claims coding is correct.
• May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
• Maintains professional client relationships.

Claims Adjuster – Workers Comp

• Adjudicates claims submitted by outside purchased services for PMC's enrolled capitated population and communicates those actions.
• Adjusts complex claims for advanced processing needs.
• Responds to Customer Service Requests and resolves problem claim situations.

• Ensure patient account and claim information contains comprehensive and accurate data to provide for timely billing and optimal reimbursement for services
• Monitor daily electronic claims transmission to research and resolve system and electronic clearinghouse claim rejection to maximize the number and percentage of patient bills processed without denials or errors
• Responsible for ensuring all claims are accurate and compliant with government rules and regulations
• Coordinate billing within the functions of registration, edits, and follow up
• Work closely and communicate with insurance companies, government payers, hospital staff, physicians, patients and others to ensure timely billing and resolution of patient accounts

Claims Specialist, Fiscal Services

• Receives and processes claims including entering/verifying claims data
• Resolves claim edits and determines benefit eligibility
• Reviews payment levels and elevates issues to supervision as necessary
• Meets production and quality standards, ensuring timely and accurate work
• Maintains accurate records including timekeeping
• Attends all required training classes

Associate Claims Processor

• Follow up on insurance denials and aged claims
• Submit claims to secondary payers and ensure accurate billing information
• Answer all information requests from payers and trace claims
• Re-submit claims to government agencies and submit claims appeals with supporting documentation

Senior Claims Specialist – Insurance Follow-Up

• 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

• Interact with policyholders, agents, claimants, witnesses, attorneys, contractors, public adjusters and other vendors/partners to facilitate accurate, prompt claims resolution.
• Effectively manage fluctuating workload, with low to moderate supervision, while maintaining focus on claims quality and customer experience.
• Conduct physical inspections at the scene of loss to determine scope of damage and control estimates provided by vendors.
• Collaborate with other internal departments in recognizing and referring claims involving SIU, subrogation, auto physical damage, and total loss.
• Build rapport with policyholders, customers, agents, carriers, attorneys and vendors to facilitate prompt and accurate claim resolution.
• Apply case and statutory law in the proactive adjustment of moderate to complex property claims located in Washington and Oregon.
• Accurately interpret coverage using experienced level contract, regulatory and compliance knowledge, following company file handling procedures.
• Issue timely claims payments with a moderate level of claims payment authority; present files outside of authority level for review and approval.
• Direct and coordinate vendors and experts in order to achieve restoration project timeline goals while keeping insured apprised, ensuring remarkable customer experience.
• Occasional CAT duty as needed.
• Demonstrate behaviors consistent with PEMCO's policies, values, code of ethics, and business conduct.
• Authentically support the PEMCO Brand and are constantly on the lookout for top talent to join us to achieve our Mission to Worry Less and Live More.
• Other duties as assigned.

Senior Property Claims Adjuster

• Receives and processes claims including entering/verifying claims data; determines if claim information is complete and correct.
• Resolves claim edits, reviews history records and determines benefit eligibility for service.
• Reviews payment levels to arrive at final payment determination; elevates issues to next level of supervision, as appropriate.
• Meets all production and quality standards, ensuring timeliness and accuracy of all work.
• Maintains accurate records including timekeeping records.
• Attends all required training classes.

Claims Processor

• Research and resolve all claims and authorizations exceptions using internal resources.
• Provide communication to providers as necessary regarding the status of a claim or authorization.
• Follow up with providers on all financial implications of reprocessed claims or authorizations.
• Transport all claims entered by processors from image software to proprietary software for review.
• Utilizing knowledge of system, research current queues of work to find claims requiring further research and correction.
• Research and resolve any claim and authorization issues to determine best resolution.
• Work with internal departments to resolve issues involving authorization or claim handling.
• Recoup any overpayments to providers resulting from changes to a claim or authorization processing by posting to the provider account.
• Log all claims and authorizations that cannot be resolved and send rejection letters to providers.
• Using knowledge of authorizations, hold certain payments pending the outcome of client review.
• Adjudicate claims and send for payments ensuring that all proper documentation is attached.
• Complete daily audit of claims entered by Claim Intake representative.
• Take any incoming calls from providers or members regarding authorizations, benefits, or claim status.
• Provide backup to Accounts Receivable Assistant or Authorization Representative as needed.
• Develop and/or communicate methods to improve productivity and efficiency.
• Assist with gathering data for client audits.
• Contribute to the team effort by accomplishing additional responsibilities as needed.
• Assist with training of new staff members.

• Investigate, evaluate and settle more complex first and third-party commercial insurance property claims.
• Evaluate each claim in light of facts; Affirm or deny coverage; investigate to establish proper reserves; and settle or deny claims in a fair and expeditious manner.
• Communicate with all relevant parties and document communication as well as results of investigation.
• Thoroughly understand coverages, policy terms and conditions for broad insurance areas, products or special contracts.
• Travel is required to attend customer service calls, mediations, and other legal proceedings.

Claims Specialist – Property

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Claims Specialist II

• Investigating basic and occasionally moderately complex auto insurance claims.
• Evaluating coverage, determining liability, and negotiating settlements.
• Working directly with claimants, insureds, and other involved parties to ensure timely, accurate, and customer-focused claim resolution.
• Ensuring compliance with all regulatory requirements and company standards throughout the claim lifecycle.
• Preparing clear, concise claim summaries.
• Conducting recorded statements with claimants, insureds, and witnesses.
• Maintaining detailed and well-documented claim files, including notes, summaries, and decision rationale.
• Collaborating with internal teams to support efficient and customer-centric claim handling.

Inside Auto Claims Adjuster

• Provide concierge-level customer service to one of Group Insurance’s largest clients
• Take a consultative approach in guiding and coaching our client’s employees through the life cycle of a disability claim
• Deliver world-class service that ensures a more effortless experience for the employee
• Engage Expert Resources to further enhance the claim journey, addressing Behavioral Health and Vocational opportunities within their block of claims
• Interact directly with the Leave team at the client during quarterly virtual meetings
• Interface daily with the client’s Benefits Business Partners
• Seek out opportunities to further enhance the claimant experience
• Serve as an ambassador for continuous process improvement within the Concierge Team
• Oversee a block of complex claims, including those with co-morbidities, behavioral health issues, and self-reported symptoms

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Senior Property Claims Adjuster

Claims Processor

Claims Specialist

Claims Specialist – Property

Claims Specialist II

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Senior Disability Claims Examiner