Senior Claims Specialist

Overview

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Pay

Base pay range : $90,000.00 / yr - $100,000.00 / yr

Job

The Claims Specialist is responsible for evaluating, processing, and managing liability, property, auto, general liability claims, and employment claims in compliance with state regulations; documenting activities; conveying information regarding claims and / or benefits; and providing testimony in benefit disputes while exercising discretion, independent judgment, critical thinking skills and demonstrating exemplary customer service skills.

Responsibilities

• Evaluate, manage and adjudicate liability, property, auto, general liability, and employment claims in compliance with state regulations.
• Adjudicate auto and general liability claims to determine validity and reach closure in accordance with legal requirements and state statutes.
• Analyze liability exposure for branches to determine appropriate actions.
• Attend legal hearings, settlement conferences, and mediations to provide testimony and monitor proceedings.
• Maintain claims files and records to document actions and ensure compliance with policies and legal requirements.
• Oversee claims handling and third-party providers to ensure compliance with legal regulations per state.
• Prepare statistical summaries, evaluations, reports, and oral presentations to document activities.
• Respond to inquiries from claimants, districts, and involved personnel to resolve issues and facilitate communication.
• Provide timely, balanced, and accurate claims reviews, documentation, and decisions in a time-sensitive environment in accordance with regulations.
• Serve as the face of the company, communicating with claimants and their representatives with empathy and active listening, and providing updates and explanations regarding the claim process and benefits.
• Document conversations within claim files with appropriate detail and professional writing.
• Interact with claimants, customers, health care providers, attorneys, brokers, and family members during claim evaluation.
• Assemble file documentation and correspondence requiring extensive policy analysis and factual detail.
• Analyze information to determine if additional information is needed for a reasonable claims determination.
• Collaborate with external and internal resources (physicians, attorneys, vocational consultants) to gather data to support well-reasoned claim decisions.
• Identify and reconcile inconsistencies during evaluations and collaborate with underwriting and Fraud Waste and Abuse resources as needed.
• Identify offsets and calculate monthly benefits after the elimination period, including COLA, Social Security Offsets, Residual Disability, and non-routine payments.
• Address and resolve escalated customer complaints in a timely manner.
• Perform other duties as assigned.
• Demonstrate strong time management, ability to work on multiple tasks with deadlines, and attention to detail.

Qualifications & Skills

Benefits & Work Environment

ESOP Retirement Benefits extended after one year of service with typical discretionary annual company contributions ranging from 10% to 15% of annual salary. 401K Retirement Benefits extended to non-union employees. Health, Dental, and Vision and other supplemental health insurance. PTO and Holiday Pay. Opportunities for career advancement. On-the-job training provided. Work for an industry leader in various disciplines and markets.

Physical Demands

The physical demands described are representative of those needed to perform essential job functions. Reasonable accommodations may be made for individuals with disabilities. The following are regularly required :

Job Details

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