Under the direction of the Claims Team Leader, the Claims Representative investigates and resolves claims promptly, equitably, and in accordance with established best practices.
Major Duties & Responsibilities
Duties may include, but are not limited to:
- Receive and review new claim assignments.
- Analyze claim and policy information to provide background for investigations and determine the extent of policy obligations.
- Contact, interview, and obtain statements (recorded or in person) from insureds, claimants, witnesses, physicians, attorneys, police officers, and other relevant parties to gather necessary claim information.
- Arrange for surveys and engage experts as appropriate.
- Evaluate facts obtained during investigations to determine liability and the company’s obligations under the policy contract.
- Prepare reports on investigations, settlements, denials, and evaluations of involved parties.
- Set reserves within authority limits and recommend reserve changes to the Team Leader as needed.
- Review claim progress and status with the Team Leader, discussing challenges and recommending solutions.
- Manage litigation files in a timely and appropriate manner.
- Assist the Team Leader in developing methods and improvements for claim handling.
- Settle claims promptly and equitably.
- Obtain releases, proofs of loss, or compensation agreements and issue company payments for claims and related expenses.
- Inform claimants, insureds, agents, or attorneys of claim denials when applicable.
- Assist the Team Leader and company attorneys in preparing cases for trial, including arranging witness attendance and taking statements, while continuing efforts to resolve claims before trial.
- Refer claims to subrogation when appropriate.
- Participate in claim file reviews and audits with customers, insureds, and brokers as needed.
- Administer benefits in a timely and appropriate manner, maintaining control of the claim resolution process to minimize current and future exposure.
- Establish and maintain strong relationships with customers, agents, underwriters, and experts.
Depending on the line of business, additional duties may include:
- Maintaining system logs.
- Investigating compensability and benefit entitlement.
- Reviewing and approving medical bill payments or forwarding for external review as necessary.
- Managing vocational rehabilitation.
Scope Information
This position reports directly to a Claims Team Leader or another member of the claims management team.