Claims Adjuster II – EMC Claims Solutions

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• *This position is eligible to work from home anywhere in the United States**

Summary: Initiates contact within 24-hour for both clients and claimants for general liability, and auto liability claims. Exercises independent judgment in the investigation, negotiation, and disposition of multiple line, multi-state claims and losses of moderate complexity within limitations of authority in the client contract; and according to claims handling instructions within the contract; and within applicable laws. Essential Functions:

• Analyzes coverage to ensure loss is covered by client policy
• Initiates contact within 24-hour for both clients and claimants for general liability claims
• Completes thorough investigation by determining facts of loss and taking statements from client, claimants, and/or witnesses
• Analyzes loss details and develops a plan of action to efficiently and accurately reach resolution on claims presented
• Sets timely, adequate reserves to cover client’s probable ultimate exposure in accordance with specific client claim handling procedures
• Reviews collected medical records to evaluate injury as a factor in the determination of compensability and ongoing medical management
• Reviews bills, invoices and receipts for accuracy and processing
• Identifies subrogation potential on every claim which includes review of police and fire department reports and pursues recovery accordingly
• Identifies risk factors and determines if referral for additional handling such as Estimatics Review Unit, Special Investigation Unit, Subrogation, or Medical Review, is necessary (with client approval)
• Identifies complex claims that require escalation and initiates discussion with people leader
• Prepares information for jurisdictional state filings for workers’ compensation claims
• Maintains active diaries and a plans of action in line with client handling instructions
• Promptly responds to all inquiries and refers requests for account inquiries to Claims Management
• Remains up to date with individual client handling instructions to ensure accurate handling of all claims
• Prepares claims summary reports for clients and participates in file reviews per client handling instructions
• Prepares mandatory reporting for excess carriers according to defined carrier reporting requirements
• Responds to questions from clients, agents, claimants, lawyers or coworkers
• Investigates and reviews questions of coverage, liability and the value of claims and lossesÂ
• Issues denial letters when appropriate
• Negotiates settlement amounts for damages claimed within assigned authority limits. Makes recommendations to management for settlement amounts outside of authority limits, and follows case to conclusion for training purposes as appropriate.Â
• Issues payments within check authority limit
• Issues settlement documents and verifies that they are properly executed
• Prepares bodily injury and/or property damage evaluations, negotiation ranges and target settlement figures
• Performs Medicare compliance functions
• Gathers information and serves as a resource for claim lawsuits, mediations and arbitrations
• Remains current on jurisdictional and industry related developments within the respective line of business through internal and external training opportunities
• Ensure all continuing education units (CEU’s) and professional licenses are kept up-to-date as per requirements of the relevant jurisdictions

Education & Experience:

• Bachelor’s degree or equivalent relevant experience
• Three years of claims adjusting experience or related experience
• Prior experience with a third-party administrator (TPA) preferred
• INS, AIC, SCLA, WCLA and CPCU designations preferred

Knowledge, Skills & Abilities:

• Strong knowledge of the theory and practice of the claim function
• Strong analytical, investigative, and problem-solving abilities with respect to liability and coverage
• Strong knowledge of insurance contracts, medical terminology and legal aspects of court procedures affecting legal liability for all lines of insurance
• Strong computer skills, including claims systems
• Strong organizational, written, and verbal communication skills, including documentation
• Good ability to advise, partner, and effectively consult with diverse internal and external stakeholders
• Occasional travel required; a valid driver’s license with an acceptable motor vehicle report per company standards required if driving

The hiring salary range for this position will vary based on geographic location, falling within either of the following: $66,294 - $91,570 or $73,245 - $100,731 A hiring range represents a subset of the full salary range. The actual salary will depend on several factors, including relevant education, skills, and experience of an applicant, geographic location, and business needs.   For information relating to the benefits EMC Team Members receive as part of a comprehensive rewards package, please visit www.emcins.com/careers. Our employment practices are in accordance with the laws that prohibit discrimination due to race, color, creed, sex, sexual orientation, gender identity, genetic information, religion, age, national origin or ancestry, physical or mental disability, medical condition, veteran status, active military status, citizenship status, marital status or any other consideration made unlawful by federal, state, or local laws. All of our locations are tobacco free including in company vehicles. Apply tot his job Apply To this Job