Claims Examiner Associate

Pharmacists Mutual Insurance Company Algona , IA 50511

Posted 3 months ago

Pharmacists Mutual has an opening for a Claims Examiner Associate. This position will investigate, evaluate, reserve, negotiate and resolve assigned claims in accordance with Company guidelines. The Examiner will provide timely, professional claim handling and superior customer service.

Claims Examiner Associate

  • Contact members to obtain claims information.

  • Complete documentation of claims damages.

  • Determine coverage and method of inspection, including the coordination of adjusters.

  • Manage timely settlement of claims.

  • Conduct settlement negotiations with members and claimants.

  • Handle low severity, high frequency claims with clear coverage.

  • Identify fraud and subrogation opportunities.

  • Provides unit support functions as assigned including data entry, reporting, documentation, etc.

Essential Functions

Essential functions may include, but are not limited to the following:

  • Provide superior customer service and ensures file quality, timely coverage analysis and communication with insured based on application of policy information to facts or allegations of each case.

  • Directly investigate each claim through prompt and strategically-appropriate contact with applicable parties such as policyholders, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts to determine the extent of liability, damages, and contribution potential.

  • Actively engage in the identification, selection and direction of appropriate internal and/or external resources for specific activities required to effectively evaluate claims, such as Subro, Risk Management, Medical Director, Nurse Consultants, and fire or fraud investigators, as well as other experts.

  • Interview witnesses and take necessary statement; completes outside investigation as needed per case specifics.

  • Maintain claim files and documents claim file activities in accordance with established protocols, guidelines, procedures, and metrics.

  • Establish and maintains proper indemnity and expense reserves.

  • Recommend, attend, and/or present at claims roundtable for collaboration of technical expertise.

  • Develop and employ creative resolution strategies.

  • Negotiate disposition of claims with insureds and claimants or their legal representatives.

  • Attend depositions, mediations, arbitrations, pre-trials, trials and all other legal proceedings, as needed.

  • Evaluate all claims for recovery potential; assists in recovery efforts and/or engage and direct Company resources for recovery efforts.

Knowledge, Skills and Abilities

  • Understand principles and practices of insurance claims examination.

  • Understand complex policy and contract coverage.

  • Demonstrate empathy to those who suffered a loss.

  • Ability and flexibility to work longer hours when workload fluctuations occur.

  • Ability to multi-task and handle large volumes of work in a short period of time.

  • Research and stay up-to-date with trends and changes in the claims/insurance industry.

  • Appropriately deal with information that is considered personal and confidential.

  • Obtain and use sensitive information discreetly and objectively, both internal and external.

  • Communicate effectively with others (oral and written).

  • Analyze complex issues and make critical decisions.

  • Correct English usage, spelling, grammar, vocabulary and punctuation.

  • Maintain records, prepare reports and conduct correspondence related to the work.

  • Interpret and apply laws, rules and regulation, as well as complex policy and contract coverage.

  • Determines when to escalate concerns to the appropriate level of management.

  • Follow oral and written directions.

  • Work effectively with others in a team environment.

  • Contribute effectively to the accomplishment of team or work unit goals, objectives and activities.

  • Establish and maintain effective working relationships with those contacted in the course of work.

  • Excellent customer service skills.

  • Ability to organize and prioritize work.

  • Work independently and demonstrate drive and initiative.

  • Ability to handle multiple tasks at once.

  • Ability to meet definite deadlines and deal with pressure situations.

  • Collect, interpret, and input data efficiently and accurately.

  • Use computer and related software effectively.

  • Use Microsoft Office programs efficiently and effectively.

Experience and Education Qualifications

Claims Examiner Associate

  • High School Diploma or equivalent and 5 years of experience; or

  • Associate's Degree or equivalent and 3 years of related experience; or

  • Bachelor's Degree

Special Requirements, Licenses and Certificates

  • Licensing required in some states.
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Essential functions may include, but are not limited to the following: * Provide superior customer service and ensures file quality, timely coverage analysis and communication with insured based on application of policy information to facts or allegations of each case. * Directly investigate each claim through prompt and strategically-appropriate contact with applicable parties such as policyholders, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts to determine the extent of liability, damages, and contribution potential. * Actively engage in the identification, selection and direction of appropriate internal and/or external resources for specific activities required to effectively evaluate claims, such as Subro, Risk Management, Medical Director, Nurse Consultants, and fire or fraud investigators, as well as other experts. * Interview witnesses and take necessary statement; completes outside investigation as needed per case specifics. * Maintain claim files and documents claim file activities in accordance with established protocols, guidelines, procedures, and metrics. * Establish and maintains proper indemnity and expense reserves. * Recommend, attend, and/or present at claims roundtable for collaboration of technical expertise. * Develop and employ creative resolution strategies. * Negotiate disposition of claims with insureds and claimants or their legal representatives. * Attend depositions, mediations, arbitrations, pre-trials, trials and all other legal proceedings, as needed. * Evaluate all claims for recovery potential; assists in recovery efforts and/or engage and direct Company resources for recovery efforts. Knowledge, Skills and Abilities * Understand principles and practices of insurance claims examination. * Understand complex policy and contract coverage. * Demonstrate empathy to those who suffered a loss. * Ability and flexibility to work longer hours when workload fluctuations occur. * Ability to multi-task and handle large volumes of work in a short period of time. * Research and stay up-to-date with trends and changes in the claims/insurance industry. * Appropriately deal with information that is considered personal and confidential. * Obtain and use sensitive information discreetly and objectively, both internal and external. * Communicate effectively with others (oral and written). * Analyze complex issues and make critical decisions. * Correct English usage, spelling, grammar, vocabulary and punctuation. * Maintain records, prepare reports and conduct correspondence related to the work. * Interpret and apply laws, rules and regulation, as well as complex policy and contract coverage. * Determines when to escalate concerns to the appropriate level of management. * Follow oral and written directions. * Work effectively with others in a team environment. * Contribute effectively to the accomplishment of team or work unit goals, objectives and activities. * Establish and maintain effective working relationships with those contacted in the course of work. * Excellent customer service skills. * Ability to organize and prioritize work. * Work independently and demonstrate drive and initiative. * Ability to handle multiple tasks at once. * Ability to meet definite deadlines and deal with pressure situations. * Collect, interpret, and input data efficiently and accurately. * Use computer and related software effectively. * Use Microsoft Office programs efficiently and effectively. Experience and Education Qualifications Claims Examiner I * High School Diploma or equivalent and 5 years of experience; or * Associate's Degree or equivalent and 3 years of related experience; or * Bachelor's Degree Claims Examiner II * High School Diploma or equivalent and 7 years of related experience; or * Associate's Degree or equivalent and 5 years of related experience; or * Bachelor's Degree and 3 years of related experience; or * Master's Degree Special Requirements, Licenses and Certificates * Licensing required in some states. Pharmacists Mutual Insurance Company Algona IA

Claims Examiner Associate

Pharmacists Mutual Insurance Company