Examine claims data, investigate the facts of loss, determine coverage and liability, and adjusts claims within limit of authority. Claims involved are usually subject to standardized procedures which lead to a settlement with limited exercise of discretion. Claims involved occasionally require analysis and may require research to resolve coverage and/or damage issues. There is supervisory review of ongoing progress and results of work. There is more focused supervision on all complex files.
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.
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
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
May handle more complex files with appropriate supervision to develop skills
Develop a working knowledge of systems and technology used within the company
Identify customer needs and work to meet those needs using appropriate customer service skills
Required 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
Demonstrate the capability of consistently handling aggregate file exposures of at least $2,500
Demonstrate proficiency in file audits to agreed standard of efficient claims quality
Has a basic command of the claims policies and procedures; exhibit basic interpretation of policies & procedures in resolving claims, but may still need some assistance from supervisor
Demonstrate the ability to interpret and