Claim Specialist

• Handle commercial auto physical damage claims, PIP/MedPay matters, and minor to moderate bodily injury claims within assigned authority
• Review new assignments, verify policies, vehicle schedules, coverages, and endorsements
• Make documented liability determinations using reports, statements, photographs, dashcam, telematics, and scene information
• Triage and route claims to appropriate handling channels
• Evaluate physical damage and total losses; review appraisals, supplements, and repair invoices
• Manage rental, loss-of-use, towing, and storage exposures
• Investigate and resolve minor to moderate bodily injury claims; establish reserves and escalate claims as required
• Identify total losses, evaluate diminished value claims, and manage salvage protocols
• Identify subrogation and fraud opportunities; pursue recovery and make SIU referrals
• Maintain claim files, diaries, reserves, payments, and settlement documentation
• Communicate with insureds, claimants, brokers, and fleet managers through phone, email, text, and digital portals
• Support continuous improvement and reporting for cycle time, severity, total loss rate, recovery, and customer satisfaction

Auto Physical Damage Claim Specialist

• Review assigned claims and contact insureds and other affected parties
• Set expectations for the remainder of the claim process and initiate documentation in the claim handling system
• Complete complex coverage analyses and identify all possible policyholder benefits
• Create additional sub-claims when needed
• Investigate claim facts to determine payment eligibility, applicable limits or exclusions, and recovery potential
• Review damages and determine applicability of state law and other claim-related factors
• Evaluate the financial value of losses
• Approve payments for appropriate parties
• Refer claims to Underwriting, Recovery Units, or the Claims Special Investigation Unit when necessary
• Document and code claim files and complete claim closure activities in the claims management system
• Negotiate claim settlements
• Handle Michigan PIP claims involving MCCA, quadriplegic injuries, traumatic brain injuries, amputations, and other catastrophic injuries
• Work with insureds, guardians, conservators, attorneys, treatment teams, and case managers to obtain information and complete claim reviews
• Make appropriate claim determinations

Senior Claim Specialist

• Handle and document incoming/outgoing claim calls
• Provide resolution to customer questions and educate customers on the claim process
• Initiate and complete claim settlement transactions fitting the express claim criteria
• Deliver an unparalleled customer service experience
• Follow documented department claim procedures and good faith claim handling guidelines
• Handle escalated calls with complex problems
• Assist with procedure and policy documentation
• Make claim determinations and settle express claims
• Identify claims for follow-up or complex claim handling
• Educate members on policy provisions and exclusions
• Interpret financial and non-financial information online and follow claim requirements and procedures

Claim Specialist I

• Manage claims returned which have failed scrub rules
• Identify and resolve payer rejections in a timely manner
• Enter charges/bills into EMR in coordination with the certified coding team/Coding manager
• Monitor missing charges and communicate with RCM management as needed
• Contact payers when necessary to resolve issues
• Report trends preventing successful claim submission to RCM leadership
• Communicate effectively with Coding, AR/Follow-up, Patient Services, and Posting departments
• Enter bills/charges with input from the certified coding team when necessary

Claim Edit Specialist – Laboratory

• Review assigned claims
• Contact insureds and other affected parties
• Set expectations for the remainder of the claim process
• Initiate documentation in the claim handling system
• Complete complex coverage analysis
• Identify all possible policyholder benefits
• Create additional sub-claims when needed
• Investigate claim facts to determine payment, applicable limits or exclusions, and recovery potential
• Review damages and determine the applicability of state law and other claim factors
• Evaluate the financial value of losses
• Approve payments for appropriate parties
• Refer claims to Underwriting, Recovery Units, or the Claims Special Investigation Unit when necessary
• Document and code claim files and complete claim closure activities in the claims management system
• Negotiate claim settlements

Casualty Claim Specialist

• Evaluate coverage, assess claim exposures, and make informed decisions for fair and timely resolutions
• Manage challenging and complex claims involving members, medical providers, attorneys, and internal partners
• Review assigned claims and initiate claim-handling activities
• Contact insureds and affected parties to gather information and set expectations
• Document claim activity and maintain accurate records in the claims management system
• Perform complex coverage analysis and identify applicable policyholder benefits
• Establish and manage sub-claims
• Investigate coverage applicability, claim validity, policy limits, exclusions, and recovery opportunities
• Analyze claim facts, damages, state laws, and other factors affecting claim decisions
• Evaluate loss values and authorize appropriate claim payments
• Negotiate settlements and claim resolutions
• Refer claims to Underwriting, Recovery Units, and the Claims Special Investigation Unit when necessary
• Complete claim documentation, coding, closure activities, and compliance processes
• Handle intermediate to complex Michigan Personal Injury Protection claims, including fractures, mild closed head injuries, surgical procedures, and attendant care claims
• Manage claims involving the Michigan Catastrophic Claims Association
• Handle attorney-represented claims and legal involvement throughout the claim process
• Investigate and manage losses extending beyond standard PIP scenarios
• Collaborate with insureds, physician offices, medical providers, and insurance carriers to obtain documentation and information
• Review medical and claim-related information to determine coverage and payments
• Maintain compliance with state regulations, company policies, and claim-handling standards

• Review assigned claims and contact insureds and other affected parties
• Set expectations for the remainder of the claim process and initiate documentation in the claim handling system
• Complete complex coverage analysis and identify all possible policyholder benefits
• Create additional sub-claims when needed
• Investigate claim facts to determine payment, applicable limits or exclusions, and recovery potential
• Review damages and determine applicability of state law and other claim factors
• Evaluate the financial value of losses
• Approve payments for appropriate parties
• Refer claims to Underwriting, Recovery Units, Claims Special Investigation Unit, or other company units when necessary
• Thoroughly document and code claim files and complete claim closure activities in the claims management system
• Negotiate claim settlements
• Handle Michigan PIP claims involving MCCA, quadriplegic injuries, traumatic brain injuries, amputations, and other catastrophic injuries
• Work with insureds, guardians, conservators, attorneys, treatment teams, and case managers to obtain necessary information and complete claim reviews
• Make appropriate claim determinations

• Review assigned Michigan Personal Injury Protection (PIP) claims
• Contact insureds and other affected parties and set expectations for the claim process
• Initiate and maintain documentation in the claim handling system
• Complete complex coverage analysis and identify all applicable policyholder benefits
• Create additional sub-claims when needed
• Investigate claim facts to determine payment, applicable limits or exclusions, and recovery potential
• Review damages and determine applicability of state law and other claim-related factors
• Evaluate the financial value of losses
• Approve payments for appropriate parties
• Refer claims to Underwriting, Recovery Units, Claims Special Investigation Unit, or other company units when necessary
• Document and code claim files and complete closure and related activities in the claims management system
• Negotiate claim settlements
• Handle claims involving MCCA, quadriplegic injuries, traumatic brain injuries, amputations, and other catastrophic injuries
• Work with insureds, guardians, conservators, attorneys, treatment teams, and case managers to obtain information and complete claim reviews
• Make appropriate claim determinations
• Occasionally travel for meetings, collaborative activities, or team-building activities as specified by leadership

Senior Claim Specialist, Medical Management Unit

• Review assigned claims
• Contact insureds and other affected parties
• Set expectations for the claim process and initiate documentation in the claim handling system
• Complete complex coverage analysis
• Identify all possible policyholder benefits
• Create additional sub-claims when needed
• Investigate claim facts to determine payment, applicable limits or exclusions, and recovery potential
• Review damages and determine applicability of state law and other claim factors
• Evaluate the financial value of losses
• Approve payments for appropriate parties
• Refer claims to Underwriting, Recovery Units, or the Claims Special Investigation Unit when necessary
• Document and code claim files and complete closure activities in the claims management system
• Negotiate claim settlements
• Handle Homeowner/CAT field claims valued over $100,000
• Investigate claims requiring in-depth coverage analysis
• Prepare damage estimates using claims software for field claims
• Review estimates for accuracy
• Monitor contractor repair status when needed
• Assist the Claim Manager with file reviews and training when needed
• Conduct on-site property inspections and assess damage
• Guide policyholders through the claims process
• Support catastrophe response efforts for large-scale weather events and natural disasters
• Travel within the assigned local market approximately 10% of the time, with no overnight travel and a company vehicle provided
• Work a hybrid field schedule Monday–Friday, 8:30 AM–5:30 PM EST

Property Field Claim Specialist

• Review and adjudicate complex, sensitive, and specialized medical claims according to established plan processing guidelines
• Provide subject matter expertise, coaching, and guidance on escalated or technically challenging issues
• Support customer service operations by addressing inquiries and resolving issues
• Review pre-specified claims and claims exceeding specialist adjudication authority or processing expertise
• Apply medical necessity guidelines, determine coverage, verify eligibility, identify discrepancies, and implement cost-containment measures
• Ensure regulatory compliance and verify payments align with company policies and procedures
• Identify and report potential overpayments, underpayments, and other claim irregularities
• Perform claim rework calculations
• Train and mentor team members as needed
• Conduct outbound calls to obtain required information for claims or reconsideration requests

Claim Specialist jobs in United States

Auto Physical Damage Claim Specialist

Senior Claim Specialist

Claim Specialist I

Claim Edit Specialist – Laboratory

Casualty Claim Specialist