Examine claims data, investigate the facts of loss, determine coverage and liability, and adjusts claims within limit of authority. This position is located in the Buffalo, NY office.
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.
- 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; process payments timely 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
- Responsibilities include but are not limited to: reviewing a person’s injuries and loss of earnings claims after an accident; analysis of coverage and conducting investigation of injuries and causal relationship to claim; proactively interact with healthcare professionals to monitor treatment and disability and determine need for independent medical examinations; maintain cost containment practices regarding indemnity and expense payments on claims; negotiate claims with insured’s, claimants, attorneys and providers; recognize and investigate recovery possibilities; comply with state regulatory requirements and maintain work according to individual/company goals; work in a team environment; other duties as assigned.
- 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
- May oversee files that use, but not limited to: medical management tools, such as case management, independent medical examinations and peer review; may oversee large loss, litigation and catastrophic losses.
- Shadow and learn the above stated essential duties and responsibilities
- 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
- Develop and learn the NYS Fee Schedule and a basic understanding of anatomical terminology associated with injury claims, CPT and ICD coding
- Develop and learn NYS Regulation 68
- 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
- Minimum Skills and Competencies:
- The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Bachelor’s Degree or in-lieu of degree equivalent education, training and work-related experience
- Successfully completes Claim Representative trainee program, or equivalent external training program
- Proficient in Microsoft Office (Word, Excel, Outlook, PowerPoint)
- Obtain/Maintain appropriate licensing or educational requirements as a New York State license is required or will be obtained within the 1st 90 days
- Demonstrate proficiency in file audits to agreed standard of efficient claims quality
- High degree of initiative, mature judgment, and discretion
- Ability to resolve conflicts and empathize with customers is critical
- Demonstrate professional oral and written communication skills
- Organization and time management skills are critical for this position
- Demonstrate an understanding of insurance law as it relates to claims
- Knowledge of no-fault regulatory requirements for the state of New York (NY)