To analyze complex or technically difficult claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.
• Analyzes and manages 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 resolves claims within evaluation.
• Negotiates settlement of claims within designated authority.
• Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
• Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams 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 be not limited to subrogation, Second Injury Fund excess recoveries and Social Security and Medicare 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 claimant 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.
When applicable and appropriate, consideration will be given to reasonable accommodations.
Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Computer keyboarding, travel as required
Hearing, vision and talking
Credit security clearance, confirmed via a background credit check, is required for this position.
The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.
- Customer Service
- Performs other duties as assigned.
- Supports the organization's quality program(s).
- Travels as required.
- Four (4) years of claims management experience or equivalent combination of education and experience required.
- • 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 and Medicare application procedure 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
• Good interpersonal skills
• Excellent negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Service Expectations
- Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. Licenses as required.
-Ranked Top 500 Asian-Owned & Asian Pacific American-Owned Businesses in the US -Ranked Top 100 Diversity-Owned & Privately-Owned Businesses in California -Ranked INC500 Fastest Growing Private Companies -Ranked Top 100 Largest Women Owned Business San Francisco Business Times -Ranked 50 Largest Minority-Owned Companies San Francisco Business Times - Ranked in Top 100 Woman Owned Business in the US, Diversity Business -Ranked in the Top 10 Minority-Owned Businesses in the Philadelphia Business Journal -Ranked in the Top 50 Woman-Owned Businesses in the 2014 Philadelphia Business Journal