Claims Specialist

• 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
• complete training and development of the Company’s claims training program for the assigned line of insurance
• 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

Claims Representative

• Responsible for the resolution of high complexity and high exposure Workers Compensation claims in multiple jurisdictions
• Confirms coverage of claims by reviewing policies and documents submitted in support of claims
• Analyzes coverage and communicates coverage positions
• Conducts, coordinates, and directs investigation into loss facts and extent of damages
• Directs and monitors assignments to experts and outside counsel
• Evaluates information on coverage, compensability, and medical management to determine the extent of insured's exposure
• Sets reserves within authority or makes claim recommendations concerning reserve changes to manager
• Focus on driving claims to a resolution with a focus of returning the injured back to work
• Evaluate, Negotiate and settle claim when appropriate
• Prepares reports by collecting and summarizing information
• Adheres to Fair Claims Practices regulations and internal Claims Quality Performance Objectives
• Participates in special projects or assists other team members as requested
• Attend all state specific trainings as scheduled
• Travel to mediations, trials, and conferences as required

Claims Examiner III, Workers Compensation

• Responsible for the resolution of moderate complexity and moderate exposure first party property claims in multiple jurisdictions.
• Handles low to moderate low exposure claims.
• Confirms coverage of claims by reviewing policies and documents submitted in support of claims.
• Analyzes coverage and communicates coverage positions.
• Ability to draft coverage position letters independently.
• Utilizes acceptable investigation claims handling and settlement techniques that achieve cost effective and timely closure results by obtaining, reviewing and analyzing documentation, policy provisions and other records.
• Conducts, coordinates, and directs investigation into loss facts and extent of damages.
• Evaluates information on coverage, liability, and damages to determine the extent of insured's exposure.
• Sets reserves within authority or makes recommendations concerning reserve changes to manager.
• Utilizes diary system to pro-actively resolve outstanding issues and to ensure timely processing and closure of the claim.
• Negotiates and settles claims directly with claimant.
• Prepares reports by collecting and summarizing information.
• Participates in special projects or assists other team members as requested.
• Provides timely service throughout the life cycle of the claim by meeting all service level agreements, initiating timely contact to all appropriate parties, and responding to incoming inquiries according to company policy and procedures.
• Identifies subrogation opportunities and fraud potential and makes appropriate referrals.

Claims Examiner II

• Investigate and resolve claims within assigned authority
• Determine coverage and liability
• Negotiate settlements with insureds, claimants, and attorneys
• Maintain accurate documentation and reserving
• Communicate promptly and professionally with all stakeholders
• Collaborate with internal teams and external partners
• Adhere to audit and compliance standards
• Participate in training and team initiatives

Senior Claims Representative

• Analyzes and processes complex claims
• Works with high exposure claims involving litigation
• Ensures ongoing claims within service expectations, industry best practices and specific client service requirements
• Identifies and pursues potential third-party subrogation recoveries associated with highest exposure/complexity claims
• Reviews high exposure, complex multi-jurisdictional claims to establish potential for third party subrogation recovery
• Provides subrogation guidance and direction to both internal and external stakeholders
• Develops and pursues third party subrogation
• Sends appropriate subrogation lien notifications to appropriate parties
• Gathers information necessary to support viable subrogation claims
• Provides direction to assigned subrogation counsel
• Maintains a diary on active claims with subrogation potential
• Approves and makes timely claim payments relative to subrogation
• Manages claim recoveries, including but not limited to subrogation
• Prepares status reports for clients as required
• Manages the litigation process
• Develops training material and leads department training opportunities.

Claims Representative, Recovery

• 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

Claims Examiner, Auto – Bodily Injury

• Analyze mid- and higher-level general auto claims to determine scope of damages
• Ensure ongoing adjudication of claims within company standards and industry best practices
• Identify subrogation of claims and negotiate settlements
• Manage mid-level and higher-level auto commercial and personal lines claims by gathering information to determine exposure
• Assign reserve values to claims, make claims payments as necessary, and settle claims up to designated authority level
• Assess liability and resolve claims within evaluation
• Approve and process assigned claims, determine benefits due, and manage action plan pursuant to the claim or client contract
• Manage subrogation of claims and negotiate settlements
• Communicate claim action with claimant and client
• Ensure claim files are properly documented and claims coding is correct
• Maintain professional client relationships
• Perform other duties as assigned

Claims Adjuster, Auto – Property Damage

• To analyze mid- and higher-level general auto claims to determine scope of damages.
• To ensure ongoing adjudication of claims within company standards and industry best practices.
• To identify subrogation of claims and negotiate settlements.
• Manages mid-level and higher-level auto commercial and personal lines claims by gathering information to determine exposure.
• Assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level.
• Assesses liability and resolves claims within evaluation.
• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
• Communicates claim action with claimant and client.
• Ensures claim files are properly documented and claims coding is correct.
• Maintains professional client relationships.
• Performs other duties as assigned.

• Responsible for the resolution of low to moderate complexity and exposure Personal Lines Marine physical damage claims in multiple jurisdictions
• Confirms coverage of claims by reviewing policies and documents submitted in support of claims
• Analyzes coverage and communicates coverage positions
• Ability to draft coverage position letters independently
• Utilizes acceptable investigation claims handling and settlement techniques that achieve cost effective and timely closure results
• Conducts, coordinates, and directs investigation into loss facts and extent of damages
• Evaluates information on coverage, liability, and damages to determine the extent of insured's exposure
• Sets reserves within authority or makes recommendations concerning reserve changes to manager
• Utilizes diary system to pro-actively resolve outstanding issues and to ensure timely processing and closure of the claim
• Negotiates and settles claims directly with claimant
• Prepares reports by collecting and summarizing information
• Provides timely service throughout the life cycle of the claim by meeting all service level agreements
• Identifies subrogation opportunities and fraud potential and makes appropriate referrals

Claims Examiner II – Marine Personal Lines

• Responsible for processing health insurance claims submitted via paper or electronically by providers and members.
• Proficient understanding of Tapestry functionality.
• Proficient knowledge to releases health insurance claims for payment, understands claims codes according to the defined workflows.
• Proficient in the processing of claim adjustments based on appeals, configuration and/or benefit change.
• Basic knowledge of coordination of benefit functions and rules, a basic understanding of third party liability, subrogation and third party processing.
• Evaluates claims that need additional information prior to processing.
• Determines proper benefit levels that apply to claims per the certificate of insurance and/or the summary of plan documents.
• Understands the specific product lines.
• Understands accumulators for accurate monitoring of maximum out of pocket expenses for claims processing.
• Mentoring of teammates through peer-to-peer conversations.
• Processes large quantities of detailed information with high levels of accuracy.
• Investigates beneath the surface of an issue to focus systematically on root causes; communicates findings with the Senior Claims Representative.

• Review, investigate, and resolve transportation claims in accordance with company policies and procedures
• Demonstrate comprehensive knowledge of carrier services, including tracking, reporting, and billing methods
• Utilize effective problem-solving skills to verify potential claims identified by proprietary auditing systems
• Communicate information to carriers clearly, concisely, and in an organized manner
• Meet or exceed company expectations for key performance indicators
• Prioritize daily tasks of claims to be completed using time management skills
• Provide accurate and timely updates of claims information and resolutions in proprietary systems
• Escalate issues to leadership as they arise

Claims Processor

• responsible for the accurate and timely work of filing insurance claims for Exact Sciences
• demonstrate medical insurance knowledge by determining initial and/or ongoing eligibility, coverage, and related insurance reimbursement order details
• identify order and reimbursement deficiencies, route orders for appropriate actioning, and document actions taken within the systems for claims lifecycle tracking
• support the broader activities of ensuring appropriate coverage by utilizing Epic, external portals, and other software
• communicate insurance information to ancillary departments and other teams within the reimbursement operations departments

Revenue Cycle Associate I

• Responsible for the accurate and timely work of filing insurance claims for Exact Sciences
• Demonstrate medical insurance knowledge by determining initial and/or ongoing eligibility, coverage, and related insurance reimbursement order details
• Identify order and reimbursement deficiencies and route orders for appropriate actions
• Support broader activities ensuring appropriate coverage by utilizing Epic, external portals, and other software
• Monitor WQ’s for claims needing additional research and actions taken to get on the path of resolution
• Follow up with payors on unpaid aging claims
• Complete position responsibilities within the appropriate time frame while adhering to quality standards

Revenue Cycle Associate II

• Confirms coverage of personal property claims by reviewing policies and documents submitted in support of claims
• Analyzes coverage and communicates coverage positions
• Conducts, coordinates, and directs investigation into loss facts and extent of damages
• Evaluates information on coverage, liability, and damages to determine the extent of insured's exposure
• Sets reserves within authority or makes claim recommendations concerning reserve changes to manager
• Maintains accurate system data and documentation by collecting, recording, analyzing and summarizing information
• Negotiates and settles claims either directly or indirectly
• Prepares reports by collecting and summarizing information
• Identifies subrogation opportunities and fraud potential and makes appropriate referrals
• Strong emphasis on customer service to both internal and external customers is a major focus for this role particularly as it relates to service to our insureds
• Participates in special projects or assists other team members as requested
• May be asked to take on higher complexity claims as needed

Associate Claims Analyst

• To analyze and process low to mid-level auto and transportation claims.
• Processes auto property damage and lower level injury claims; assesses damage, makes payments, and ensures claim files are properly documented and correctly coded based on the policy.
• Develops and maintains action plans to ensure state required contract deadlines are met and to move the file towards prompt and appropriate resolution.
• Identifies and pursues subrogation opportunities; secures and disposes of salvage.
• Communicates claim action/processing with insured, client, and agent or broker when appropriate.
• Maintains professional client relations.
• Performs coverage, liability, and damage analysis on all claims assignments.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travels as required.

Claims Representative, Auto

• Review and monitor open claims files
• Provide assistance with coverage, liability, and damage determinations
• Review closed files and provide feedback to claim handlers
• Review open and closed files to ensure adherence to claim handling guidelines and state’s Fair Claims Practices
• Assist associates in identifying claims with subrogation potential
• Manage the arbitration process for subrogation files
• Assist in developing and presenting educational material to claim associates in classroom and remote settings
• Work effectively with associates and customers at all levels

Claims Examiner – Subrogation Claims

• Manage moderate to complex commercial claims involving bodily injury and property damage
• Independently investigating, evaluating, negotiating, and resolving third-party General Liability claims
• Assess liability and coverage, negotiate resolutions, and develop strategies that balance fairness, efficiency, and business outcomes
• Play a role in helping elevate file quality and mentor others by sharing expertise

Senior Claims Representative – 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

• Complete field inspections and related responsibilities such as reading maps and aerial photos
• Measure field and storage bins
• Discuss findings of crop loss with farmers
• Perform fact finding regarding crop damage and record information
• Transmit loss information to accurately determine potential damages
• Provide excellent service to customers – both agents and policyholders (farmers)
• Utilize company software to electronically transmit claims information directly from the field to RCIS
• Follow regulatory and company rules, policies, and procedures

Seasonal Crop Claims Adjuster

• To analyze workers compensation claims on behalf of our valued clients to determine benefits due, while ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements.
• Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim.
• Negotiating settlement of claims within designated authority.
• Communicating claim activity and processing with the claimant and the client.
• Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner.

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