PRIMARY PURPOSE: To manage claim caseload of basic to highly complex claims within granted authority level including related financial implications, along with financial implications and to mentor Account Representatives and Account Specialists.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
- Utilizes special account instructions to obtain individual customer information and adhere to instructions; identifies, initiates, and coordinates various specialized services such as subrogation, fraud evaluation or case management review to resolve claims.
- Establishes and maintains effective relationship with internal and external customers and coworkers; communicates effectively and timely.
- Mentors/coaches account representatives and account specialists; facilitates round table discussions within the assigned team.
- Investigates, evaluates and resolves claims; identifies potential problems/trends in claim files and takes corrective action or makes corrective recommendations; interprets medical reports and state law or jurisdictional law in claim handling.
- Applies jurisdictional and medical knowledge to properly assess the indemnity, medical and expense exposure of assigned claims and appropriately interprets and applies insurance coverage.
- Reviews client files and collaborates with team to prepare information which includes thorough analysis of file strategies, claims status and emerging trends.
- Proactively manages litigation in conjunction with client requirements; works constructively with client and legal representatives to resolve claims.
- Ensures compliance and best possible outcomes by minimizing financial liability.
- Compiles requirements in order to prevent penalties and fines; utilizes instructions and tools provided to ensure that all state required documentation is issued accurately and in timely manner in accordance with specific jurisdictional timeframes and guidelines.
- Monitors reports as assigned and documents compliance with key jurisdictional requirements (i.e. EDI, timeliness of benefit payments, etc.); assists Team Lead in tracking completion of team’s tasks and projects; reviews SAS/SOX documents and submits in timely manner; and assists with takeover and reverse takeover projects ensuring that claim files are transferred and handled appropriately.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
- Performs other duties as assigned.
- Supports the organization’s quality program(s).
Education & Licensing
Bachelor’s degree from an accredited college or university preferred. State adjuster licenses required.
Six (6) years of related experience and/or training or equivalent combination of education and experience required.
Skills & Knowledge
- Thorough legal and jurisdictional knowledge based on line of business
- Strong oral and written communication, including presentation skills
- PC literate, including Microsoft Office products
- Analytical and interpretive skills
- Strong organizational skills
- Excellent interpersonal skills
- Strong customer service skills
- Ability to work in a team environment
- Ability to meet or exceed Performance Competencies