Claims Examiner I

Claims Bala Cynwyd, Pennsylvania


Description

Position & Responsibilities:

  • In accordance with Company policies and in support of the Claims Department’s mission, the Claims Examiner I has the responsibility to ensure outstanding claims service.
  • Promptly investigates each claim in accordance with the claims Department Best Practices.
    • Initiates contact with insureds, claimants, witnesses, attorneys and other appropriate parties.
  • Reviews and evaluates policy coverage provisions, business classifications and underwriting guidelines.
    • Makes recommendations regarding the handling of coverage issues.
    • Composes reservation of rights letters, non-waiver agreements and coverage declination letters.
    • Under supervision directs counsel on approved declaratory judgment actions.
  • Oversees and controls investigation assignments made to independent adjusters and other vendors.
    • Reviews and audits all vendor invoices.
  • Sets initial reserves and ensures proper reserve evaluations throughout the life of a claim.
  • Maintains an organized claim file.
    • Prepares and maintains appropriate file documentation.
    • Ensures all documentation is placed in the proper folder in the ImageRight file system.
  • Maintains an effective and timely diary in accordance with Best Practices.
  • Ensures compliance with the Department’s Litigation Management Plan and Billing Guidelines for all claims in which counsel has been engaged.
  • Equitably investigates, negotiates reserves and resolves all claims within the prescribed authority level, authorized by Senior Management.
  • Recognizes and pursues potential opportunities using experienced judgement for recovery including subrogation, indemnification and/or contribution.
  • Recognizes and refers potential suspicious claims or claims activity, based on experienced judgement, to the SIU in accordance with the Claims Department Best Practices.
  • Establishes and maintains business relationships with Underwriting and reinsurers, as well as agents, insureds attorneys, vendors and other parties as appropriate.
    • Provides timely and proper notification and updates to reinsurers.
  • Participates in weekly roundtable meetings on claims issues.
  • Completes special projects and performs other duties as assigned by the Claims Manager.

Requirements & Qualifications:

  • Complete understanding of Claims Department procedures, systems and technical responsibilities.
  • Experienced claims professional who must possess the knowledge of coverage, civil and contract law, jurisdictional differences, statutory requirements and claims handling regulations.
  • Must have the ability required to recognize and resolve technical claims issues and recommend and implement solutions within the granted authority.
  • Must have an understanding of the Company’s coverages, policy forms, plus certain underwriting guidelines and classifications to make informed coverage decisions.
  • Requires excellent interpersonal skills and a high degree of initiative and decisiveness.
  • Ability to communicate with company management as well as the general public, attorneys and the company’s general agents in a professional manner.
  • Ability to communicate well with co-workers in maintaining a positive work environment.
  • Ability to effectively communicate verbally and through written reports.
  • 1-3 years of claims or related experience required.
  • Must have strong analytical skills and knowledge of policy construction, classifications and forms used by the Company.
  • Must have strong computer skills with knowledge of Windows operating systems plus Word, Excel, PowerPoint and ImageRight.
  • Must be able to effectively understand medical issues, evaluate liability and damages and have excellent negotiating skills.
  • Knowledge of the legal invoice review process (TyMetrix software) is a plus.
  • Must possess or acquire adjuster licenses and complete CE requirements as needed.
  • Must be able to travel on company business as needed.
  • College degree or equivalent work experience required.
  • Additional insurance related education/designation such as CPCU, AIC, AIM, SCLA, etc, preferred.
  • Must demonstrate a willingness to attend business related seminars and courses to enhance job knowledge.
  • Other advanced degrees are a plus.
  • The ability to work remotely as required via a personal computer and the company’s Virtual Private Network (VPN) software