Claims Representative II (Administrative)

1. PURPOSE

The Claims Representative II investigates, evaluates and resolves assigned claims in a timely and accurate manner in order to achieve a best practices type settlement within legal statutes, policy provisions and Company standards of performance or client standards (Inservco).

1. AUTHORITY -

Claims Division: 

Dimension $'s or Numbers Effective Date Accountable for the timely and accurate resolution of assigned claims

Claims:

Manages approximately 1,700 claims per year.  Per claim authority level up to $15K dependent upon, experience and competency

 

Inservco:

Manages approximately 2400 claims per year with an average monetary authority subject to, and dependent upon, experience and competency.

2020

1. COMPETENCIES AND ESSENTIAL DUTIES

Competency Description of Duties Business Acumen

• Prepares claim file documentation accurately and completely, to include all relevant oral and written statements, photos, facts and environmental factors present at the scene of the accident.

Negotiation

• Makes appropriate contacts and negotiating with policyholders, claimants, third parties, medical and legal professionals in the processes of arbitration, litigation, subrogation, contribution and salvage.
• Achieves a best practices type settlement in the disposition of assigned claims, to include:
  • assessing all costs and determining first and third party liabilities associated with the settlement of auto property damage, non-complex workers' compensation, property losses and simple bodily injury claims.

Results Oriented

• Effectively identifies and pursues subrogation and salvage opportunities, when available.

Time & Priority Management

• Performs basic and intermediate claims handling duties on assigned claims in a timely manner.
• Verifies coverage and policy provisions in order to identify the claim's insurability or compensability.
• Takes responsibility for handling and resolving policyholder/self-insured/claimant problems or requests.
• At the direction of the Team Leader, may perform limited field work, limited claim handling on workers' compensation lost time claims of low exposure/low complexity, as well as low exposure/low complexity bodily injury liability claims.

Decision Making

• Analyzes and resolves coverage and liability issues or questions.
• Gathers and evaluates factual information that enhances identification of underlying problems or opportunities pertaining to assigned claims.
• Generates alternative solutions to problems or situations involving assigned claims.
• Setting or adjusting reserves in accordance with the degree of liability and value of the claim.

Performs other duties as may be assigned by the CSO Team Leader Multi/WC

Claims Service Office Manager II, or CSO Team Leader

1. CORPORATE CORE COMPETENCIES

Competency Proficiency Description Effectively Communicates and Connects

• Communicates and negotiates effectively with peers regarding work outcomes.
• Influences by making a strong case, bringing other people on the team to understand the presented viewpoint.
• Provides feedback and is clear when disagreeing with an approach; offers suggestions for improvement.
• Attentively listens and asks clarifying questions and paraphrases to enhance understanding.
• Build and nurture positive relationships within the workplace.

Customer Focused

• Identifies explicit and implied customer needs.
• Asks probing questions to fully understand business requirements.
• Develops positive relationships with customers by meeting their needs as well as incorporating their feedback.
• Responds quickly and takes action with high quality solutions that address needs and improve overall customer experience.
• Owns resolution of customer experience outcome.

Talent Development Mindset

• Discuss technical and professional development with peers to gain suggestions for further development.
• Actively seek and act on opportunities to recognize peers for high performance.
• Stays alert to identify learning opportunities for self.

Demonstrates Adaptability

 

 

 

 

 

 

 

• Contributes to progressive thinking within the team by posing questions that challenge traditional methods or processes.
• Proposes ideas and suggests new approaches to tackling own work tasks and issues in a better way to drive organization success.
• Participate in and actively support change initiatives, and provide ideas to promote their success.
• Recognizes and manages an ambiguous work environment.
• Demonstrates flexibility in generating alternative solutions and recommendations.

Demonstrates Accountability

• Applies judgment in making decisions about own work, and takes responsibility for actions.
• Demonstrates reliability by producing steady work results and delivering on commitments to team members on time.
• Takes responsibility for regularly seeking and applying feedback and actively learning from errors and setbacks.
• Understands the mission of the organization.

1. SPECIAL RELATIONSHIPS

• The Claims Representative II reports to the assigned CSO Team Leader Multi/WC,

Claims Service Office Manager II or CSO Team Leader

• The Claims Representative II has direct contact and interacts with all levels of personnel within the Claims Service Office
• Occasionally interacts with underwriting personnel regarding claim issues
• May occasionally interact with agents
• Has direct contact with policyholders/claimants, third parties, medical/legal professionals, vendors

      VI. QUALIFICATIONS

Education/

Credentials

• High school diploma or equivalent
• Bachelor's degree preferred
• Adjuster's license or be willing to obtain one as required

Experience

• Successful completion of Claims Representative II Trainee curriculum

or a minimum of 1 year experience in a property/casualty claims handling position.

Technical/ Professional Knowledge

• Effective communication skills, both oral and written
• Effective inter-personal skills
• Effective organization skills, with the ability to work independently
• Must be detail oriented, as assigned work requires significant attention to detail
• Personal Computer skills, with an emphasis on Microsoft products
• Ability to work within a team-oriented, fast-paced, customer-focused environment
• Basic understanding of tort and state laws applicable to assigned claims
• Basic understanding of the Unfair Claims Settlement Practices Act, insurance policy coverages and provisions, and medical, legal, automotive and construction terminology

1. JOB REQUIREMENTS (as required by ADA – Americans with Disabilities Act)

• This position is primarily a sedentary position that requires occasional standing and walking throughout the office environment.
• Must be able to see and effectively use a computer monitor.
• Must be able to operate a computer, keyboard and applicable printers and other general office equipment.
• Must be able to access and enter information accurately using automated systems.
• Must be able to hear and communicate via the telephone and/or monitoring devices to both internal and external clients.
• Must be able to present information to individuals and groups.
• Must be able to interpret and apply concepts that may or may not be based upon established guidelines.
• Must be able to maintain acceptable attendance and adhere to scheduled work hours.
• Must have a valid driver's license and be able to operate a motor vehicle.
• Must be able to travel, with overnight stays required.
• Must be dependable and able to adhere to scheduled work hours