2023-365 BI Claims Adjuster III

Description

Job Description:

Handle a caseload up to 150 pending claims that may include some levels of complexity.  Requires establishing facts of loss, coverage analysis, investigation, compensability/liability/negligence determination, coordination of medical care (as appropriate), litigation management, damage assessment, settlement negotiations, identifying potential fraud, vendor management, reserve analysis, and report completion.  Ability to attend conferences, client meetings, mentor other adjusters and assist management as needed.   Ensure compliance with state statutes, client guidelines and NARS Best Practices.  Address claim metrics in a timely and appropriate manner. Perform other miscellaneous duties as assigned, which may include travel. 

 

 

                Essential Duties and Responsibilities:

 

              Coverage:

• Identify, analyze, and confirm coverage.

 

Customer Service/Contact:

• Make first contact within parties and client within eight (8) business hours.
• Communicate with parties and providers to determine liability, compensability, negligence, and subrogation potential.
• Obtain necessary information and explain benefits as appropriate.  Maintain regular contact throughout the life of the claim process.
• Answer phones, check voice mail regularly, and return calls as needed.
• Assist with training/mentoring of Claims Adjusters.
• Assist management when required with projects or leadership as requested.
• Support management and handle various duties/responsibilities of the Assistant Unit Manager/Unit Manager as delegated in their absence.

 

Subrogation:

• Refer all files identified with subrogation potential to the subrogation department.
• Maintain closing ratio as dictated by management team.
• Close all files as appropriate in a timely and complete manner.

 

Investigation:

• Verify facts of loss and pertinent claims facts such as employment, wages, or damages and establish disability with treating physicians as appropriate.
• Identify cases for settlement.  Evaluate claims and request authority no later than 30 days prior to mediation date and negotiate settlement.
• Evaluate and negotiate liens.
• Recognize and report potential fraud cases.

 

Litigation Management:

• Develop and direct a litigation plan with defense attorney (if assigned), utilizing all defenses and tools to bring the file to closure.  Ensure all filings and state mandated forms are completed timely.  Litigated files must be diarized effectively based on current activity, but no greater than every 60 days.
• Review claim files involving active litigation monthly at minimum, and document responses to filings, development of defenses, depositions, and timely referral to defense counsel.
• Direct the actions of defense counsel on litigated files.
• Attend mediations and trials as required for cost effective litigation management.

 

Reserves:

• Establish ultimate reserves (anticipated cost to bring file to close based on known facts) as soon as practical and monitor to adjust at the time of any exposure changing event. 
• Ensure timely payment of all known benefits in accordance with state statute. 
• Verify all provider bills have been appropriately reviewed and paid within standard timeframes.

 

Reporting Requirements:

• Report all serious injuries/liability issues and potential large loss claims to the client and/or reinsurer based upon the criteria provided by the client.
• Must pass all internal and external audits, which include those performed by regulatory agencies, carriers, and clients.
• Follow reporting requests as outlined by client files and NARS guidelines.

Qualifications

         Qualification Requirements:

 

          Education / Licensing:

• High School Diploma or equivalent required, 2-year degree or higher preferred.   
• 10+ years of prior claim adjusting experience, preferably in the line of business being handled.
• Must have 10+ years heavy litigation experience for all other lines except Worker’s Compensation
• Must possess, or can obtain, a Florida Adjuster’s license or other required jurisdictional licensing.
• Professional designations preferred.

 

         Technical Skills:

• Requires strong negotiation and litigation skills.
• Requires excellent interpersonal skills to handle sensitive and confidential situations and information.
• Requires ability to work independently.
• Requires excellent organization and time management skills.
• Requires exceptional written and verbal communication skills.

 

          Abilities:

• Requires long periods of sitting.
• Must be willing to attend local NARS office meetings, on occasion.
• Requires working indoors in environmentally controlled conditions.
• May require lifting of files and boxes up to approximately 20 pounds.
• Regular use of keyboard, mouse, computer, and exposure to computer screens.
• Requires travel for mediation, as assigned.