Handle a caseload of approximately 150 pending claims that encompass all levels of complexity. Requires establishing facts of loss, coverage analysis, investigation, compensation/liability/negligence determination, coordination of medical care (as appropriate), litigation management, damage assessment, settlement negotiations, identifying potential fraud and proper 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, the clients Claims Handling Guidelines, and NARS Best Practices. Other miscellaneous duties as assigned, which may include travel.
Essential Duties and Responsibilities:
- 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 necessary. 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.
- Must be willing and able to attend meetings by Skype or Facetime as requested.
- Refer all files identified with subrogation potential to the subrogation department.
- 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 before the mediation date and negotiate settlement valuate 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 promptly completed. Litigated files must be diaried effectively based on current activity, but no greater than every 60 days.
- Review claim files involving active litigation every month at a 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 (the anticipated cost to bring a 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 the closing ratio as dictated by the management team.
Qualification Requirements: Education / Licensing:
- High School Diploma, college degree preferred.
- Must have 7 to 10 years of overall claims experience, preferably in the line of business being handled.
- Must have 7+ years substantial litigation experience for all other lines except workers compensation.
- 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.
- Advance level of interpersonal skills to handle sensitive and confidential situations and information.
- Requires advanced ability to negotiate claims and to direct litigation.
- Must have negotiation and litigation skills for significant work with attorneys and arbitration on first and third party claims.
- Requires advanced ability to work independently.
- Requires an advanced level of organization and time management skills.
- Must possess advanced level written and verbal communication skills.
- Must be proficient in Microsoft Office applications.
- Must be able to explain and appropriately respond to auditors, clients, and potential clients during in-person presentations.
- Requires extended periods of sitting.
- Requires working indoors in environmentally controlled conditions.
- Requires lifting of files and boxes up to approximately 20 pounds.
- Repeated use of a keyboard, mouse, and exposure to computer screens.
- Requires travel as assigned, which can at times be extensive (5 to 7 days per month).