Analyze technically difficult claims to determine benefits due; work with claims involving litigation and rehabilitation; ensure ongoing adjudication of claims within standards, and to manage subrogation of claims and negotiate settlements

ESSENTIAL FUNCTIONS and RESPONSIBILITIES:

Analyzes and processes complex or technically difficult claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.

Assesses liability and resolve claims within evaluation.

Negotiates settlement of claims up to designated authority level.

Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout the life of the claim.

Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.

Prepares necessary state filings within statutory limits.

Manages the litigation process; ensures timely and cost effective claims resolution.

Coordinates vendor referrals for additional investigation and/or litigation management.

Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.

Manages claim recoveries, including but not limited to subrogation, Second Injury Fund recoveries and Social Security offsets.

Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.

Communicates claim activity and processing with the ill or injured party and the client; maintains professional client relationships.

Ensures claim files are properly documented and claims coding is correct.

Refers cases as appropriate to supervisor and management.

Maintains a quality assurance program to support the Total Performance Management initiative and the consistent delivery of quality claims service.

QUALIFICATIONS:

Education & Licensing: 

Baccalaureate degree from an accredited college or university preferred.  Licenses as required.   Professional certification as applicable to line of business preferred.

Experience:

Experience in claims management experience required.

Skills & Knowledge:

In-depth knowledge of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security application procedures as applicable to line-of-business.

Excellent oral and written communication, including presentation skills

PC literate, including Microsoft Office products

Analytical and interpretive skills

Strong organizational skills

Excellent negotiating skills

Good interpersonal skills

Ability to work in a team environment

Hours: 8:30-5:30pm