ESIS ProClaim Senior Representative, A&H

JOB DESCRIPTION

The Accident and Health Adjuster is responsible for the day-to-day management of a claim inventory involving hospital indemnity, hospital accident, and accidental death and dismemberment claims.

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

This position reports to the Team Leader.

The selected candidate should demonstrate initiative, strong organizational skills, the ability to prioritize multiple tasks, adaptability, and the ability to work effectively in a fast-paced, changing environment while meeting industry best practices and claim handling requirements.

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:


* Under limited supervision, receives assignments and reviews claim and policy information to support the investigation and determine the extent of the policy's obligation to the insured, depending on the line of business.


* Contacts, interviews, and obtains statements, recorded or in person, from insureds, claimants, witnesses, physicians, attorneys, police officers, and others to gather necessary claim information.


* Depending on the line of business, inspects and appraises damage for property losses or arranges for such appraisal.


* Evaluates facts gathered through investigation to determine the extent of liability, if any, and the company's obligation to the insured under the policy contract.


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


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


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


* Submits unusual or potentially adverse exposures to the Team Leader for review.


* Assists the Team Leader in developing methods and process improvements for claims handling.


* Settles claims promptly and fairly.


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


* Informs claimants, insureds/customers, or attorneys of claim denials when applicable.

QUALIFICATIONS



* Strong project management skills and the ability to work independently


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


* Strong written communication skills, including the ability to document policy interpretation clearly


* Strong customer service skills


* Experience using claims handling systems


* Adjuster licensing preferred


* Claims handling experience preferred


* Ability to work collaboratively, adapt to changing priorities, and contribute po...