Claims Adjusters, Examiners, and Investigators SkillsPACK

11-50 employees

Finance

Claims Adjusters, Examiners, and Investigators

Contract

In person

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Required skills

Consults policy documentation and determines the extent of coverage for claims
Resolves complex, severe exposure claims, using high service oriented file handling
Analyzes submitted claims, bills, reports, and estimates for accuracy
Settles straightforward claims in line with authority limits and adheres to organizational referral procedures
Provides policyholders with regular updates on the progress of their claims
Handles straightforward and complex claims in line with organizational policies and procedures and own authority limits and adheres to organizational referral procedures
Approves and issues payments when charges are deemed allowable and acceptable
Examines claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments
Follows own organization’s guidelines for referral of claims to stakeholders
Notifies stakeholders of claims settlement decisions
Follows organizational policies and procedures where specialists are involved in investigating a claim
Identifies the legal principles that may affect the claims settlement decision and takes the appropriate action (e.g. contribution, subrogation and proximate cause)
Works within the parameters of any service standards or service level agreements with other claims management service organizations (e.g. outsourcers and third-party administrators)
Meets customer claims service standards
Complies with internal and external standards and requirements for reporting
Demonstrates an understanding of mechanisms available for resolving claims settlement disputes (eg. arbitration and mediation) and when these are used
Examines claims forms and other records to determine insurance coverage
Negotiates the settlement of complex claims to the client’s best advantage
Prepares written reports to document findings about the claim, incident, and related records
Selects and appoints external experts following own organization’s procedures and authority levels
Manages the claims handling process for straightforward claims within own authority limits to achieve timely settlement and minimize leakage
Uses claim notification information in the claims handling process for own area of business
Handles data within the prescribed sequence and execute prompt processing of claims, documentation, and payments
Identifies potential non-disclosures and misrepresentation and follows organizational procedures to deal with these situations
Applies own organization’s reserving philosophy to claims being handled
Identifies the most appropriate method of settling claims in line with organizational policies and procedures within own area of business
Creates and reviews reserves in line with market and organizational reserving policy Knows and follows the market agreements that affect claims settlement
Assesses both the customer and product provider requirements in relation to complex claims and supports the progress of claims to the mutual benefit of all stakeholders
Analyzes information gathered by investigation and report findings and recommendations
Advises clients when straightforward claims are settled and issues settlement when appropriate
Adjusts or deny claims in consideration of deductibles and policy terms
Interprets policy wordings and conditions to determine the validity of complex claims and advises the claimant accordingly
Identifies and advises the client of the prescribed or most appropriate mechanism for resolving claims settlement disputes
Follows own organization’s guidelines for referral of claims to stakeholders (e.g. early identification of large losses for underwriters and coinsurers)
Investigates, evaluates, and settles claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio
Uses mechanisms available for resolving claims settlement disputes (e.g. arbitration and mediation) and when these are used
Identifies any claims which are potentially fraudulent and follows organizational procedures for dealing with these
Gathers and verifies information from policyholders and affected parties
Identifies and resolves gaps in the key information provided for the class of business being handled
Identifies and manages potential conflicts of interest in line with organizational policies and procedures
Follows relevant protocols, market agreements and regulatory requirements that impact on the way claims are managed own area of business
Identifies when a specialist is needed to investigate a claim and follows organizational policies and procedures for appointing these
Inputs and maintains detailed and up-to-date claim files with data and analysis of coverage, damages, incident reports, correspondence, and related records
Reviews all material representation to ensure accuracy of any necessary measurement data
Handles straightforward claims in line with authority limits and adheres to organizational referral procedures