Mitsui Sumitomo Insurance Group is one of the world’s top ten property/casualty insurance carriers with over 40,000 employees worldwide. We have an opportunity available for a Senior Claims Representative to work out of our Cincinnati, OH office.
This position is responsible to adjust assigned workers’ compensation complex medical, life-time medical or lost time claims within delegated limits of authority, conduct timely and thorough investigations, and complete fair and equitable claim settlements in accordance with MSMM Claim Handling Guidelines and State Regulatory Compliance Requirements. Ensure that all services are provided in a fair, equitable and timely manner.
- Receives new claim assignments of medical only and lost time workers’ compensation claims at the moderate to complex level. Analyzes the nature of the claim to determine required investigation and handling. Determines and identifies compensability issues or questions of coverage in accordance with MSMM Claims Handling Guidelines.
- Performs timely and thorough investigations in compliance with all jurisdictional requirements and/or entitlements.
- Conducts an informed case analysis to initiate reserve changes within assigned authority and makes recommendations to supervisor or manager where assigned authority is exceeded.
- Manages, controls and negotiates timely and equitable claim payments and settlements in accordance with jurisdictional and fair claims practice requirements and company policy and procedures.
- Investigates, evaluates and resolves low to moderate level litigated files including all aspects of litigation management in accordance with MSMM Claims Handling Guidelines.
- Maintains current case diary and ensures retention of appropriate hard copy file documentation. Provides accurate claims system documentation as required by company claim manuals and procedures. Responsible for completion and/or submission of claim forms and reports as required by outside agencies.
- May handle subrogation of claims within delegated limits of authority, including identification of responsible parties, preparation of claim notice, correspondence with carriers, and negotiation of settlement in accordance with MSMM Recovery Procedures.
- Services the claim needs of our customers including insureds, claimants, brokers, etc., in accordance with company policy and procedures, and attends client visitations with underwriters and other parties to conduct presentations and reviews.
- Maintains ongoing communication with all customers throughout the claims process in an effort to provide timely and appropriate claim status as appropriate and/or required by statutory regulations.
Regulatory and Operational Compliance
- Completes timely and accurate data reports to state reporting agencies to ensured full compliance with MSMM and regulatory requirement.
- Maintains full compliance with all regulatory Fair Claim Practices Acts and state and federal regulations.
- Maintains full compliance with all state licensing and continuing education requirements to ensure current and appropriate filing/standing of all adjuster licenses.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and Experience Required:
Diploma/Degree & Experience
- High School Degree or G.E.D. is required. Bachelor's degree (B. A.) from four-year college or university is preferred.
- 2+ years of industry experience, including ability to successfully verify coverage, appropriately establish reserves, complete investigations, and understand rules associated with state regulations
If you have the required skills and experience and are interested in working in a challenging environment, please email your resume with salary requirements email@example.com
The Company is an Equal Opportunity / Affirmative Action employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.