Claims Examiner - Claims Specialist

Job Summary

The Claims Examiner will manage a caseload of low to moderate severity/complexity property and casualty insurance claims under a moderate level of supervision, depending on level of experience. Job functions include the following: Analyzing insurance claims to determine applicable coverage; Analyzing claims to determine the extent of insured's or insurer's liability; Reviewing and evaluating damages and determining strategies for resolution. Settling claims in accordance with policy provisions and within an authority level. The Claims Examiner l will engage in verbal and written communication with claimants, attorneys, and policyholders. The Claims Examiner l will ensure that all state claims handling requirements are met and internal guidelines are followed. The Claims examiner l will handle claims in accordance with established James River Claims Best Practices.

Duties and Responsibilities

• Continuously exhibit and uphold Core Values of Integrity, Accountability, Communication and Teamwork, Innovation and Customer Service.
• Conduct three point contacts
• Determine compensability
• Issue workers' compensation benefits
• Develop plans of action to resolution, coordinate return to work efforts and approved medical payments.
• Investigates Subrogation and negotiate limited settlements within authority level.
• Maintains contact with policyholders and injured workers.
• Ensure claims files are appropriately documented.
• Completes and files appropriate FROI and SROI's as required by individual State Workers' Compensation Statute and EDI reporting regulations.
• Manages claims in accordance with Falls Lake Best Practices
• Employs appropriate claims management techniques and direct intervention (referrals for nurse case management, independent medical examinations, utilization review) to manage each claim.
• Makes decisions within delegated authority.
• Have a general understanding of all legislative requirements and is able to take direction to meet those requirements in a prudent business manner.
• Maintains a license for all states and products serviced as required.
• Organize and update all reference material to reflect current legislation and regulatory compliance.
• Comply with all quality control standards set by the company for the handling of claims. Comply with all procedures set forth by the company for performing the job as it relates to the various components of claim administrative services.
• Immediately notify Management of any unusual lawyer inquiries, insurance carrier inquiries, or department of insurance inquiries.

Knowledge, Skills and Abilities

• Familiar with the claims handling process
• Knowledge of medical terminology
• Customer Service focused
• Organizational skills
• Time Management skills
• Excellent oral and written communication skills
• Attention to detail
• Strong Computer Skills
• Hands on Learner
• Ability to multi-task
• Team Attitude
• Ability to successfully obtain the required state adjusters' licenses within six (6) months following the completion of Company-provided licensure training courses and maintain appropriate licensure thereafter.

Experience and Education

Claims Examiner

• Four-year college degree preferred
• One to three years of claims handling experience
• Experience in working with liability and coverage issues
• Experience negotiating settlements with claimants and attorneys
• Multi-jurisdictional claims experience preferred, may be required depending on type of claim
• Adjuster license and/or certifications preferred

Senior Claims Examiner

• High school diploma required

• Bachelor's Degree preferred
• Minimum of three years of P&C claims handling experience including working with complex coverage issues, handling liability and coverage issues, multi-jurisdictional claims, and negotiating settlements with claimants and attorney required
• Adjuster license and/or certifications preferred

Claims Specialist

• High school diploma required
• Bachelor's Degree preferred
• Advanced Degree or Juris Doctorate Degree preferred
• Minimum of seven years of P&C claims handling experience including working with complex coverage issues, handling liability and coverage issues, multi-jurisdictional claims, and negotiating settlements with claimants and attorneys required
• Adjuster license and/or certifications desired preferred

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