Claims Specialist

• The position of Care Advocate will play a leading role in developing an innovative digital product strategy based off your deep expertise and knowledge of the long-term care needs of the aging in your market.
• You will be part of a team delivering concierge services care-seekers and care-managers including but not limited to Caregiver support and Education.
• Conducting consultations with older adults and caregivers on aging services and supports providing support and guidance on the caregiving journey.
• Unlike other traditional Care Advocacy roles, your responsibilities will not stop there but will extend to working with digital product teams to help infuse your patient-centered knowledge into the design process and provide feedback that will help create incredible digital user experiences for millions of care-seekers and care-managers at a tremendous scale.
• This role will provide Subject Matter expertise on the local and state level programming and resources for aging adults and their caregivers.
• This role will provide education and resources to aging individuals seeking assistance with care options and navigating challenges.
• Intensive case management experience and crisis intervention.
• Approach problem-solving with a human-centered lens.
• Regular document key and frequent needs of users and report qualitative data (such as quotes and anecdotal stories that representative of user needs) and quantitative data (such as frequency of user needs and trends in gaps in local care environments and resources) to the digital product and design teams.
• Bring deep understanding of landscape and individual aging and long-term resources, facilities, organizations, agencies, and referral sources to help marketing team reach key partnerships and potential consumers who would benefit from our digital products.
• Report back to product and design teams opportunities for improvement of the digital products based off of user feedback.
• Review new product features before they are released to consumers to identify improvements or potential issues to proactively improve user experience.

Associate Claims Clinical, Care Advocacy

• Complete field inspections and related responsibilities such as reading maps and aerial photos
• Measure fields, storage bins, and discuss findings of crop loss with farmers on complex non-routine claims
• Convey complex regulations and interpretations to claimants, agents, and industry people
• Perform fact-finding regarding crop damage, record information and transmit loss information
• Gather relevant facts, utilizing applicable law and establish basic principles of negligence
• Complete claim reviews and audits on lower-level adjusters
• Ensure legal compliance by maintaining a strong knowledge of regulatory and company policies
• Contribute to team effort by accomplishing related results and participating on projects as needed

Crop Claims Field Adjuster I

• 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.

Field Property Claims Adjuster

• Manage moderate to complex commercial claims involving bodily injury and property damage
• Independently investigate, evaluate, negotiate, and resolve third-party General Liability claims
• Serve as a technical resource, mentor, and trusted partner within the claims organization
• Support strong file quality, collaboration, and continuous improvement.

Senior Claims Representative – Specialty BI/GL

• Manage a range of moderate to complex claims with minimal supervision, including bodily injury, PIP, and general liability property damage
• Use critical thinking to research and develop a foundation for making coverage decisions
• Take ownership of claims from investigation through resolution
• Evaluate coverage, determine liability, assess damages, and negotiate fair settlements
• Maintain accurate reserves, manage files effectively, and present claims to committees when needed
• Draft reservation of rights and coverage denial letters

Senior Claims Representative – BI, GLPD, PIP

• Investigates, evaluates, negotiates, and resolves assigned claims
• Handles the most complex claims with minimal manager oversight
• Establishes and maintains positive relationships with customers
• Assists in building business relationships with agents, insureds and partners
• Develops and mentors other associates
• Assists leadership in training and resources development
• Maintains proper reserving through proactive investigation
• Assists other departments with investigations as required

Claims Representative, Casualty Large Loss, Auto Injury

• Investigate, evaluate, and resolve travel medical claims end-to-end
• Adjudicate benefits per policy terms and statutory requirements
• Process invoices through cost-containment networks
• Maintain clear, timely updates to customers, providers, and partners on claim status
• Document thoroughly in the claims system and ensure complete, high-quality files
• Assess the need for medical management and escalate appropriately
• Process bills in accordance with statutory requirements and internal controls
• Identify potential fraud/waste/abuse and collaborate with investigative team
• Deliver excellent written and verbal customer communication throughout the claim lifecycle
• Perform additional responsibilities as needed to support the team and our customers

Claims Adjuster

• Effectively manages a caseload of 150 or fewer workers’ compensation files
• Initiates and investigates promptly
• Determines compensability of claims and administers benefits based upon state law
• Manages medical treatment and medical billing, authorizing as appropriate
• Communicates with claimants, providers, and vendors regarding claims issues
• Computes and sets reserves within Company guidelines
• Maintains diary system for case review
• Communicates appropriate information promptly to the client to resolve claims efficiently
• Adheres to all Company policies and procedures
• Conducts file reviews as scheduled by the client and management

Workers Compensation Claims Examiner II

• Effectively manages a caseload of 150 or fewer workers’ compensation files, including complex claims.
• Initiates and investigates promptly.
• Determines compensability of claims and administers benefits based upon state law and following established Company guidelines.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Refers cases to outside defense counsel. Directs and manages as appropriate.
• Communicates with claimants, providers, and vendors regarding claims issues.
• Computes and sets reserves within Company guidelines.
• Settles and finalizes all claims and obtains authority as designated.
• Maintains diary system for case review and documents file to reflect the status and work performed on the file.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns.
• Involves TRISTAR loss control staff when appropriate.
• Adheres to all Company policies and procedures.
• Conducts file reviews independently.

Workers Compensation Claims Examiner III

• Your role is crucial in ensuring accurate and efficient processing of claims related to transportation services.
• You will be responsible for reviewing, investigating, and resolving 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 our 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 our proprietary systems.
• Escalate issues to leadership as they arise.

Claims Processor – Part-Time

• Investigate and resolve litigated claims in an efficient and accurate manner.
• Negotiate settlements and communicate effectively with policyholders, vendors, and other stakeholders.
• Verify coverages through investigation and reviewing policy terms, conditions, and language.
• Evaluate liability by taking recorded statements from involved parties and witnesses and reviewing police reports, accident scene photos, and other pertinent evidence.
• Negotiate claims settlements with claimants and their legal representation within assigned authority limits.
• Comply with industry regulations, legal requirements, and internal policies through thorough documentation of all decisions, correspondence, and discussions that occur throughout the life cycle of the claim.
• Work with and mentor other associates.

Claims Representative Specialist – Litigation

• 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).

Claims Representative, Auto – Property Damage

• 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).

Claims Representative, Auto

• Analyzes and processes complex claims, works with high exposure claims involving litigation, and 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, all lines of business across all jurisdictions.
• Reviews high exposure, complex multi-jurisdictional claims to establish potential for third party subrogation recovery by investigating and gathering information based on feasibility of recovery analysis and employment of strategies to manage the claim through timely resolution.
• Provides subrogation guidance and direction to both internal and external stakeholders to maximize recovery efforts in alignment with client, financial and jurisdictional strategy, and guidelines.
• Develops and pursues third party subrogation, refers assignments to subrogation counsel as dictated by statute or timeline, and discusses any compromised or negotiation of the claimed subrogation interest.
• Gathers information necessary to support viable subrogation claims; documents claim notes with appropriate information.
• Maintains a diary on active claims with subrogation potential and claims that meet excess reporting criteria; ensures claim files are properly documented and claims coding is correct.

Claims Representative, Recovery

• Investigate and resolve Homeowners claims of moderate complexity in a prompt and efficient manner.
• Document with photographs, measurements, recorded interviews as needed, write a repair estimate to capture damages, and complete thorough file notes.
• Ability to use imagery and advanced video technology to collaborate with onsite vendors and insureds to identify damage and write damage estimates from a virtual setting.
• Compare facts gathered during the investigation against the policy to determine coverage of claim; extend or deny coverage as appropriate.
• Establishes reserve amounts within prescribed settlement authority limit and negotiates settlement of claims; recommends claims which exceed personal authority limit to supervisor for approval.
• Responsible for effectively and timely communicating with insureds and /or their representatives to resolve issues and ensure customer satisfaction.

Property Claims Examiner II – Wind/Hail

• Manage lost time and medical only Workers' Compensation claims.
• Evaluates and establishes an action plan to manage medical and indemnity benefits associated with injury and occupational disease claims.
• Decides the outcome of the claim using sound judgment by applying established policy, procedures, regulations and guidelines.
• Gathers facts by conducting interviews with all involved parties and considers all the elements of the claim prior to issuing a decision.
• Determines eligibility of indemnity and medical benefits once salary information and medical treatment plans have been secured and processed.
• Utilize proactive reserving behaviors to ensure adequate case reserves.
• Consults with assigned claim director, return to work specialists, nurse case managers, and internal/external medical professionals.
• Works collaboratively with the injured worker, employer, outside counsel, and health and rehabilitation professionals to manage the claims costs.

Lost Time Claims Adjuster – Workers' Compensation

• 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)

Claims Representative – Auto

• Manage claims of moderate to high complexity with minimal supervision and guidance from the manager utilizing current Claim technology.
• Conduct thorough investigations in order to determine coverage, evaluate damages/benefits, and liability/compensability.
• Negotiate settlements with insureds, claimants, and attorneys.
• Maintain proactive file management and adequate reserving.
• Participate in training activities.
• Consistently exhibit a high level of customer service.
• Adhere to department audit guidelines.
• Participate in projects and initiatives as needed.

Claims Representative III

• 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 Specialist jobs in Wisconsin

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