Claims Representative II – Commercial Liability

Claims Representative II – Commercial Liability

Requirements

• Bachelor’s Degree or equivalent work experience.
• Minimum 1 year of related work experience.
• Knowledge of insurance policies and coverages, claim payment procedures, and familiarity with medical terminology preferred.
• Possess analytical abilities to review, exercise judgment, and evaluate claims to make sound decisions.
• Able to review and interpret complex and detailed documents such as contracts, medical reports, police reports, and insurance regulations.
• Effective oral and written communication skills.
• Effective time management skills while prioritizing tasks.
• Strong human relations skills.
• Ability to maintain confidentiality.
• Personal computer and math skills beneficial.
• Ability to pass required coursework applicable to job duties.
• Ability to meet travel requirements of the job to include business related assignments, with limited notice, possibly for multiple weeks as business needs arise. Travel may include driving, flying or any other necessary form of transportation.
• Acceptable motor vehicle record and a valid driver’s license.

Responsibilities

• Provide all aspects of customer service by assisting customers through difficult situations.
• Verify coverages and investigates losses by gathering pertinent information. Deny coverage where coverage does not exist.
• Support customers with empathy and understanding.
• Take recorded statements and obtain pertinent information, which may include but is not limited to police reports, medical reports, appraisals, estimates, photographs, degree of disability, rehabilitation potential. Evaluates damages/eligibility for benefits, determines liability and sets reserves.
• Evaluate claims and charges submitted by customers and/or medical providers to determine eligibility for benefits, checking for misrepresentation, preexisting conditions and mandated state benefits if applicable. Collaborates with SIU unit, as necessary, to investigate and mitigate potential fraudulent claims.
• Document all decisions, correspondence, reports and discussions that occur during an investigation.
• Settle and pay claims within assigned authority limits on a timely basis. Complete claim by evaluating the loss and settling claim.
• Detect potential problems or trends that require additional review, investigation or research and refers to Senior Claims Representative or Claims Manager for resolution.
• Confer with higher level technical claims personnel for guidance and direction to ensure the file is handled properly. Advise the Claims Department of any special problems i.e., questionable repair shops.
• Receive claim assignments from established workflow and systems.
• Adhere to state specific compliance issues for assigned jurisdictions including completion and submission of required forms.
• Determine if subrogation exists and takes steps necessary for recovery.
• Coordinate payment of benefits with other insurance carriers if applicable.
• Monitor claim files during initial and residual periods to ensure file is accurate and current.
• Refer payment or denial of claims that exceed assigned authorization limits to Senior Claims Representative or Claims Manager with settlement recommendation.
• Work closely with health facility, repair facility and/or contractors to facilitate necessary services or repair work.
• Notify Underwriting of any adverse findings on a particular risk.
• Accurately code data submitted to outside agencies or other Sentry functions.
• Participate in administering fraud control procedures, evaluating and preparing reports, and drafting responses to formal complaints.
• Obtain and maintain state adjuster licensing requirements for assigned areas.
• Performs other job-related duties as assigned from time to time.

Preferred Qualifications

• Previous insurance experience and/or coursework beneficial.