Basic Function - Determines plans of action for investigating the facts of loss, examines claims data, investigates the facts of loss, determines coverage, and adjusts claims based on the interpretation and application of case law, corporate guidelines, and statutory regulations. Claims involved frequently require analysis and may require research to resolve coverage and / or damage issues.
Demonstrates a solid understanding of insurance law as it relates to claims and handling of PIP files. Demonstrates the ability to independently find answers to more complex issues with insurance law, including reading and interpreting case law and applying to facts of the investigation.
Has a basic understanding and knowledge of state laws and regulations applicable to claims handled, including state unfair claim practice laws, and exhibit the basic ability to apply these laws and regulations as it relates to handling of PIP and / or med pay claims assigned.
May serve as mentor for others and assist with projects.
Responsible for maintaining and growing a relationship between National General Insurance and current policyholders. Also responsible for focusing on the needs of loss participants
Duties and Responsibilities - For all duties and responsibilities, incumbent will take ownership of any issue, problem, or error that could potentially impact the policyholder and / or loss participant:
10%--Receives claim assignments and verifies / investigates coverage and documents all appropriate information. Manager involvement with review of some claims to ensure they are commensurate with ability.
15%--Establishes an investigative plan; initiates investigation by gathering facts and evidence with all interested parties; completes appropriate reports; and takes recorded statements when necessary. Reviews loss reserves and adjusts or opens / identifies hidden exposures as necessary. Recognizes loss exposures meeting the large loss requirement and completing large loss reporting. Identifies liability exposures.
15%--Analyzes, evaluates and adjusts claims within limit of authority in compliance with statutory regulations and fair claim practices; makes decisions on best options. Summarizes claims in excess of authority and submits to manager for approval. Evaluates settlement alternatives by reviewing regulatory compliance and fair claims practices; makes decisions on best option. Makes appropriate contacts to discuss a settlement; extends an offer to appropriate party; documents all file activity and settlement information in file notes clearly outlining basis for settlement. May handle more complex files, including litigation, with appropriate supervision, to develop skills.
50%--Review and analysis of medical claims, including, but not limited to, the analysis and interpretation of medical records and reports and utilization of Independent Medical Examinations, peer reviews, case management, coding reviews, and Diagnostic Related Group (DRG) audits.
5%--Learns how to determine subrogation or fraud potential and how to handle. May refer claim to appropriate business unit for further handling.
5%--Performs other projects and assignments as directed, including, but not limited to, handling reinsurance claims (reporting and periodic updating to the reinsurer, proper file documentation required by the reinsurer, and requesting reimbursement), assisting in training PIP trainees and other PIP Reps, and participates in investigations of fraudulent and other claims with possible attendance at depositions and EUOs.