ESIS ProClaim Senior Representative

JOB DESCRIPTION

ESIS ProClaim is seeking an experienced Senior Claims Representative.

Reporting to the AVP and VP of Claims, as well as the Claims Team Leader, this role is responsible for reviewing coverage, investigating third-party claims, securing evidence, assessing subrogation, recovery, and tenders, apportioning liability, and settling claims to achieve optimal outcomes in accordance with established best practices and client instructions.

Key Duties and Responsibilities:


* Determine coverage, conduct thorough investigations, and assess the extent of policy obligations based on the line of business.


* Maintain a diary system to ensure each file is reviewed at least every 90 days.


* Collaborate effectively with defense counsel and litigation teams, as directed by the client.


* Prepare detailed 90-day Claim Summary Reports and provide updates to clients on investigations, settlement opportunities, claim denials, reservation of rights, third-party tenders, and recommendations for claims review meetings.


* Post loss and expense reserves in the claims system within authority limits; recommend reserve changes above authority to AVP and/or VP of Claims.


* Review claim progress and status with claims leadership, discussing issues, opportunities, tasks, and remedial actions.


* Submit to claims leadership any unusual or potentially undesirable exposures, such as allegations of bad faith or unfair claim practices.


* Assist claims leadership in developing improvements to claims handling procedures.


* Work with Partnership Leaders to deliver results, attend meetings, and participate in claim reviews.


* Review and confirm that claims professionals have secured appropriate releases, proofs of loss, or compensation agreements, and issue payments for claims.


* Maintain claims files with accurate notes, reports, photos, and documentation.


* Adhere to all company and regulatory compliance requirements.


* Update claims promptly with Medicare data and address Medicare reporting and interests.


* Meet or exceed performance goals.

QUALIFICATIONS



* Advanced technical knowledge and competence in claims handling, demonstrated by a minimum of 5 years of experience in a specific line of business (Auto & General Liability).

Experience in a third-party administrator (TPA) environment is strongly preferred.


* Ability to obtain and maintain required state licenses.


* Comprehensive understanding of coverage, applicable legal principles, and litigation management.


* Knowledge of auto liability cost containment programs and proven account management skills.


* Excellent communication, negotiation, and interpersonal skills for effective interaction with internal and external stakeholders at all organizational levels.


* Strong analytical and problem-solving abilities.


* Demonstrated ability to consistently deliver superior service to customers.

An applicable resident...