Senior Claim Examiner I

Overview

The Resolution Adjuster is responsible for prompt and independent review of insurance claims, through effective research, evaluation, investigation, negotiation and interaction with insureds, claimants, and counsel.  The Adjuster is assigned to mid-sized and / or mid-complexity claims in the line of business. Maintains a solid understanding of AmTrust’s mission, vision, and values. Upholds the standards of the AmTrust Claims organization.

 

This position will focus on long tail / aged New York WC Claims. 

Responsibilities

 

• Investigates the claim or coverage by making timely and appropriate contact with involved or interested parties including but not limited to the insured or employer representatives, claimant or injured workers, witnesses and producers.
• Analyzes coverage that may or may not be applicable to the claim by policy or statutes. Reviews coverage issues as needed and drafts positions as required.
• Establishes reserves based on estimating most likely outcome of a claim based on the facts for the case and company standard. Adjust reserves based on facts, company standard and experience.
• Occasionally claims adjusted by an Adjuster II / III will involve working with internal or assigned Legal Counsel. Build strong relationships, applying company principles and standards in partnership with internal legal counsel.
• Effectively negotiates litigated & non-litigated claims. Gains trust of other parties to negotiations and demonstrates good sense of timing. 
• Depending on the type of claim may:
• Communicate with internal Managed Care and Medical resources to ensure coordination with Medical providers on the development and authorization of appropriate treatment plans as well as accurate billing.
• Obtain medical records and reports, police, ambulance and agency reports; photographs and measurements.
• Leverages and builds critical thinking and decision-making skills to gather, assess, analyze, question, verify, interpret and understand key or root issues.
• Writes in a clear, succinct and fact-based manner in Claims files as well as in other communication.
• Demonstrates ability to learn technical materials and learns from mistakes.
• Manages time and diary entries effective and efficiently, prioritizing work in a fast-paced environment.
• Establishes and maintains effective relationships with customers and gains their respect and trust.
• Performs other functional duties as requested or required.

Unique Responsibilities:

• Completes basic compensability analysis based upon AOE/COE investigation.
• Verifies nature and extent of injuries.
• Able to identify change in claim exposure.
• Possesses a high level of technical claim and legal knowledge and skills.
• Excellent communication both written and oral.
• Ability to professionally interact at a high level with parties both internal and external to AmTrust.
• Easily adapts to changing situations, requirements, or priorities.
• Ability to effectively influence others without damaging relationships.
• Skillful negotiator.

Qualifications

 

• Bachelor’s degree or equivalent experience
• 3+ years claims handling experience
• Preferred experience handling litigated or complex claims
• State licensure as required
• Demonstrated proficiency with MS Office suites
• Demonstrated skills in investigation, evaluation and negotiation
• Strong knowledge of insurance theory and practices
• Ability to travel is required for some positions

 

Preferred:

• • Multijurisdictional experience may be required
  • CPCU, ARM, AIC or other claims certifications