No Fault Adjuster
- Career Level
- Not Specified
York Risk Services Group is a premier provider of insurance, risk management, alternative risk, pool administration and claims management solutions to clients across hundreds of industries. Recently named by Forbes as one of "America's Best Midsized Companies 2017" We firmly believe that our employees drive the success of the company. With success in mind as the ultimate goal, we strive to create and provide an environment that offers challenging, stimulating and financially rewarding opportunities.
The No Fault Adjuster candidate is an experienced claims professional who specializes in handling all levels of No Fault losses. A New York license and experience with New Yorks Regulation 68 is required. Multi-state claims experience is a plus, with experience in New York, Florida, Michigan and New Jersey preferred. The candidate will be expected to grow into a pending of claims from every PIP state, so s/he will be expected to obtain and maintain licenses in PIP states with licensing requirements within a reasonable period.
ESSENTIAL JOB RESPONSIBILITIES:
- Evaluate coverage based on an investigation that includes, but is not limited to, the claim report, the insurance policy, memorandum of coverage and applicable statutes and case law to determine if a claim can be accepted as being within coverage. Determine coverage aspects and prepare coverage letters as necessary.
Report to the client, the broker and the carrier as requested. Evaluate compliance with the applicable governmental statutes and take or recommend appropriate action. Identify time constraints particular to the statutes of each PIP state and address medical billing timely, utilizing the state-appropriate form(s) and referring bills as needed to approved vendors for pricing. Identify key coverage and damages issues; develop plan and conduct investigation utilizing appropriate methods of investigation according to type of coverage and nature of the exposure. Investigation shall be in accordance with contractual obligations and prevailing professional standards
- Obtain and evaluate medical records, utilizing independent medical examination vendors when a question arises of causal relationship or maximum medical improvement being reached.
- Calculate the extent of the clients financial exposure with respect to claims, including but not limited to estimated medical expenses, lost wages, transportation and attendant care costs and analyze information to set case reserves for use by clients and applicable regulatory authorities. Revise case reserves based on diverse factors including additional evidentiary and medical developments in the course of adjusting the claims.
- Have a sense of awareness to fraud factors and implement Special Investigation procedures if insurance fraud factors are detected.
- Resolve claims within assigned levels of authority as set forth in client account instructions and consistent with company policies and guidelines.
- Use analysis of situation to recommend appropriate experts for testimony regarding damages and liability or, when not to use said experts.
- Involve client in decision-making as set forth in client account instructions and consistent with company policies and guidelines is required. Determine when to involve the client in decision-making by applying clients instructions and corporate guidelines.
- Collaborate with co-workers on analysis of situations by being able to apply knowledge appropriately and communicate same effectively.
- Be available for after-hours calls from clients for immediate analysis and response to accident scenes or loss locations to conduct appropriate investigation and / or claim management.
- May plan the work of support staff members and may have some involvement with the coaching, developing, training and appraisal processes for subordinate team members.
- Based on experience, analysis and discretion, manage litigation.
- New York State license required. Licenses in Michigan and Florida a plus.
- Experience handling multi-state No Fault claims, applying the statutes of each individual PIP state to the claim presented. Apply principles of investigation management including, but not limited to, immediate situational evaluation; case value analysis preliminary and ongoing; application of investigative tools; evaluation of medical bills, including the use of approved pricing vendors; determining coverage and application of coverage to claims; litigation management; client management; resolution of claims.
- Minimum of 5-7 years of industry experience in handling No Fault losses. Demonstrated successful track record of handling complex claims, including coverage issues. Experience with transportation network companies a plus.
- Superior negotiation skills, oral and written communication and presentation skills
- Analytical and interpretive skills
- Strong organizational skills, including setting priorities
- Well-developed interpersonal skills and customer service skills
- Work well under pressure
- Spanish fluency is a plus
- Proficient in Microsoft Office Suite.