PRIMARY PURPOSE:
Examine claims data, investigate the facts of loss, determine coverage and liability, and adjusts claims within limit of authority.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Following is a summary of the essential functions for this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.
- Establish an investigative plan; initiate investigation by gathering facts and evidence with all interested parties; complete appropriate reports; take recorded statements when necessary, may review loss reserves and adjust or opens hidden exposures as necessary
- Evaluate and adjust claims within limit of authority and summarize claims in excess of authority and submit to manager for approval
- Evaluate settlement alternatives by reviewing regulatory compliance and fair claims practices; make decisions on best option
- Make appropriate contacts to discuss a settlement; extend an offer to appropriate party; document all file activity and payment/settlement information in file notes clearly outlining basis for settlement
- Determine subrogation or fraud potential and refer to Unit when potential exists or handle to conclusion
- Identify customer needs and work to meet those needs using appropriate customer service skills
- Develop an understanding of the functions of other departments, such as Policy Ops and Marketing
Trainee
- Shadow and learn the above stated essential duties and responsibilities
- Learn to handle most aspects of auto claims
- Develop a basic understanding of the content of policies written by the company
- Develop a basic understanding of the insurance industry and the organizational relationships of the company
- Learn how to determine subrogation or fraud potential and how to handle
- Develop a basic understanding of systems and technology used within the company
Level I
- Receive claim assignments and verify/investigate coverage and document all appropriate information before Manager is involved with review of claims to ensure they are commensurate with ability
- May handle more complex files with appropriate supervision to develop skills
- Develop a working knowledge of systems and technology used within the company
Level II
- Claims involved frequently require analysis and may require research to resolve coverage and/or damage issues
- Periodic review of ongoing activities and results of work
- Focused supervision on complex files; the CRII will handle complex files on a regular basis)
- Receive claim assignments and verifies/investigates coverage and documents all appropriate information
- Determine claim approval and or denial up to $7,500 per exposure or $10,000 per file
- If handling PIP may participate in investigations of medical providers and attend EUOs
- May work with attorneys in resolving lawsuits
- Conduct negotiations and settlements within authority level, using independent judgment, or within discretionary levels granted above individual authority level
- Track and document the quality of service provided by defense counsel and manage litigation and recovery costs
- May assist in training of Claims Representatives
- Proficient in using all systems and technology used within the company
- May be required to make personal appearances on behalf of the company when requested