Handle a caseload of approximately 150 pending claims that encompass all 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 and appropriate use of authorized vendors. Also includes timely and appropriate reserve analysis and report completion. Ability to attend conferences, client meetings, mentor other adjusters and assist management as requested. All file handling must be within state statutes, Client Claims Handling Guidelines and NARS Best Practices. Other miscellaneous duties as assigned, which may include travel
- Identify, analyze and confirm coverage.
- Contact appropriate parties and providers to determine liability, compensability, negligence and subrogation potential.
- Contact appropriate parties to obtain any needed information and explain benefits as appropriate.
- Continue contact throughout the life of the file as appropriate.
- 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.
- Handle the various duties/responsibilities of the Assistant Unit Manager/Unit Manager as delegated in their absence.
- Refer all files identified with subrogation potential to the subrogation department. 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.
- 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 diaried effectively based on current activity, but no greater than every 60 days.
- Review claim files involving active litigation on a monthly basis 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.
- 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.
- Pay all known benefits, ensuring they are paid timely on state statute.
- Verify all provider bills have been appropriately reviewed and paid within standard timeframes.
- 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.
- Document plan of action in the claim system and set appropriate diaries.
- Maintain a regular diary for monitoring and directing medical care, case development, or litigation.
- Close all files as appropriate in a timely and complete manner.
- Maintain closing ratio as dictated by management team.
Education / Licensing:
- High School Diploma, college degree preferred.
- Must have 7+ years prior claim adjusting or similar experience, with the majority handling complex litigation.
- Must have 7 to 10 years of overall claims experience in GL including Environmental Insurance coverage forms and claims.
- Must have 7+ years heavy litigation experience for all other lines except workers compensation.
- Must have 5+ years Construction Defect or similar/related experience if handling that line of business.
- Must be eligible for reserve/payment authority level of $50,000+ when appropriate
- Must possess, or have the ability to obtain, a Florida Adjuster’s license or other required jurisdictional licensing..