Senior Claims Representative-Legal Claims

• Claim Evaluation: Investigate and evaluate insurance claims to determine coverage, liability, and potential damages. Review policy terms and conditions to assess the validity of claims and ensure compliance with company policies and industry regulations. Prepare coverage letters to insureds that explain the carrier’s coverage position, including any bases for reserving rights or denying coverage.
• Documentation and Reporting: Collect and analyze relevant information, such as photographs and other proof of loss to document the claim. Prepare detailed reports summarizing findings, including coverage analysis, damage assessments, and settlement/reserve recommendations.
• Customer Service: Communicate with claimants, policyholders, and other stakeholders to gather information, address concerns, and provide updates on claim status. Provide exceptional customer service by responding promptly to inquiries and maintaining professional and empathetic communication.
• Implement Program Guidelines and PCM Procedures: Thoroughly understand and follow relevant Program Guidelines that are specific to any programs in which you are involved. To the extent that specific Program Guidelines are not available for a given program, understand and follow PCM Procedures.
• Investigation and Negotiation: Conduct thorough investigations by interviewing involved parties, inspecting damaged property, and reviewing police reports or medical records. Negotiate fair settlements with claimants, adhering to company guidelines, legal requirements, and industry standards. You may be required to attend off-site investigations, inspections, mediations, meetings, and hearings, as needed.
• Policy Interpretation: Interpret insurance policies and coverage terms to determine the extent of coverage and any applicable exclusions. Advise policyholders and claimants on their rights, obligations, and potential outcomes related to the claim. Draft clear and concise coverage letters to insureds, summarizing the results of the coverage investigation and explaining the decision on coverage, if applicable. Ensure that the coverage letters are accurate, informative, and adhere to carrier guidelines and legal requirements.
• Collaboration: Collaborate with internal units, including management, coverage, and accounting. Attend conference calls, presentations, and roundtables with management and the carriers, including being prepared to present claims, your investigation, coverage, and participate in discussions of strategy.
• Claims Management System: Maintain accurate and up-to-date claim records, utilizing digital systems and databases. This includes attaching all emails and documents to the claims system, maintaining a diary, documenting all phone calls and meetings in the file notes, and making sure that all necessary fields have been completed and updated accurately and timely. Monitor the progress of claims, meet established deadlines, and ensure compliance with regulatory requirements.
• Continuous Learning: Stay updated on insurance industry trends, regulations, and emerging technologies relevant to claim adjusting. Participate in training programs and professional development activities to enhance knowledge and skills.

Skills, knowledge & expertise