ESIS ProClaim Representative, A&H

JOB DESCRIPTION

The Accident & Health and Travel Adjuster is responsible for the day-to-day management of an inventory of travel, hospital indemnity, hospital accident, and accidental death and dismemberment claims.

This role reviews medical and travel documentation, investigates losses, interprets policy language to make coverage and payment determinations, sets and evaluates reserves, prepares coverage letters and reports, and delivers high-quality customer service.

This position reports directly to the Team Leader.

The selected candidate should be able to prioritize work effectively, manage multiple tasks, adapt to changing priorities, and meet claim handling standards and industry best practices in a fast-paced environment.

The selected candidate will be required to work in the office a minimum of three days per week.

Position Responsibilities

Duties include, but are not limited to:


* Reviews claim and policy information under limited supervision to support investigations and determine the company's obligation to the insured, depending on the line of business.


* Contacts and interviews insureds, claimants, witnesses, physicians, attorneys, police officers, and other relevant parties to obtain necessary claim information.


* Assesses travel-related losses, including trip cancellation, trip interruption, medical emergencies, baggage loss, travel delays, and other covered events.


* Evaluates facts gathered through investigation to determine liability and the company's obligation under the policy contract.


* Prepares reports related to investigations, settlements, claim denials, and evaluations of involved parties.


* Maintains detailed claim notes, accurate documentation, and complete file records.


* Responds to customer inquiries professionally and provides clear status updates.


* Ensures timely claim handling in accordance with service standards and regulatory requirements.


* Sets reserves within authority limits and recommends reserve changes to the Team Leader.


* Reviews claim progress with the Team Leader and discusses issues and recommended actions.


* Identifies unusual or potentially adverse exposures and escalates them to the Team Leader as needed.


* Assists the Team Leader in developing improved claims handling methods and processes.


* Settles claims promptly and equitably.


* Obtains releases, proofs of loss, or compensation agreements and issues claim payments.


* Identifies potential fraud indicators and escalates suspicious claims when appropriate.


* Communicates claim outcomes to claimants, insureds/customers, or attorneys.


* Supports quality, compliance, and continuous improvement efforts in claims handling.

QUALIFICATIONS



* Strong time management skills and the ability to work independently


* Proficiency with Microsoft Office applications, including Excel, Word, and PowerPoint


* Strong written communication skills, including ...