Claims Specialist

General Search & Recruitement Published: August 7, 2018
Location
Job Type
Category
Job ID
Job-1211

Description

Claims
Specialist

Fresno, CA

The Claims Specialist
serves as a critical interface between the insured and the Company for
insured’s with claims by maintaining responsibility for direct case
investigation and management, while exercising defined, independent reserving
authority and executing the resolution process as determined by the claim
evaluation standards.  

 You
must be able to perform each essential duty satisfactorily. The essential
functions listed below are representative of the knowledge, skill, and/or
ability required with or without reasonable accommodation.

You may be required to do
any and all of these duties for case management/ investigation of claims,
depending on specific needs of the assigned unit.

      
Investigates cases from initial contact to resolution including research,
analysis and synthesis of all medical facts; conducts in-depth interviews;
prepare detailed and comprehensive written reports; assign attorney(s) and
secures consultant reviews; directs and monitors attorney work product and
executes recommendations regarding case resolution.

Confirms coverage and resolves
coverage issues.

Evaluates liability and damage
information to establish consistent and appropriate indemnity and ALAE
reserves.  Provides required documentation.

Communicates with reinsurers and other
involved parties in monitoring and resolving cases as appropriate.

Approves bills and controls
expense functions.

Monitors trial
activities and negotiates settlements within given authority, including direct
negotiation with plaintiffs and plaintiff attorneys.

     
Serves as a primary contact for ongoing customer communications and services
regarding claim related matters.

      Prepares and presents appropriate cases for all internal reviews.

      Attends litigation-related activities including, but not limited to,
arbitrations, mediations, settlement conferences, pre-trial conferences and
trials.

      
Assists with various Team and Departmental projects as needed.  

      
Performs other duties as assigned.

      General
office environment is primarily sedentary work which requires the following
physical activities: standing, sitting, walking, reaching, lifting, finger
dexterity, grasping, repetitive motions, talking, hearing and visual acuity.


    EEducation:

       BS/BA
degree in business or related field, or commensurate work experience is
required. 

  Experience Required:

  5 years experience in claims handling/investigation preferred

Skills
Required:

       Able to
plan and carry out short and long-range activities and assign priorities.

       May be
required to work independently in a telecommuting environment.

       Able to
exercise independent judgment and understand and communicate complex medical
and legal concepts.

       Excellent
communication skills in conducting in-depth investigations with insured’s and
others.

      Prepare and effectively present
comprehensive reports and recommendations using proper English, grammar and
spelling.

       Maintain
confidentiality while conducting sensitive investigations.

       Establish
and maintain effective working relationships with public and other
professionals.

       Proficiency
in MS Office including Word, Excel, and PowerPoint. 

 

       Excellent Health Benefits including Medical, Dental
& Vision effective on 1st day of employment

       Employee Bonus Program

      Healthcare Flexible Spending & Dependent Care
Accounts

      

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