Claims Specialist

• Manage complex claims inventories requiring advanced technical expertise and strategic claim handling
• Communicate with policyholders, agents, attorneys, and witnesses to gather information and provide customer service
• Investigate claims to determine exposure, work with experts, and make strategic recommendations
• Use mediation, negotiation, denial, litigation, or offers to drive claim resolutions
• Follow state or governing-entity rules, regulations, and internal claims-handling policies
• Direct defense counsel throughout litigation and monitor legal fees and costs
• Collaborate with cross-functional team members on projects and process discussions
• Recommend process improvements and industry best practices
• Ensure claims-system data accuracy for regulatory reporting
• Provide knowledge transfer and mentor or train less experienced team members
• Prepare and present claims status reports for internal and external stakeholders
• Administer, manage, and approve benefits payments to injured workers within designated authority
• Create and adjust reserves in accordance with company policies
• Resolve claims fairly and equitably while providing legally required timely benefits
• Support specialty claim programs and strategic initiatives involving complex litigation, medical exposure, catastrophic injuries, fatalities, PTD, and long-duration claims
• Provide technical guidance to leadership on complex claim resolution strategies
• Drive resolution of complex or long-duration claims through settlement, reserving, and medical-management strategies

Claims Specialist – Workers' Compensation

• Analyze complex or technically difficult workers' compensation claims to determine benefits due
• Investigate claims and gather information to determine claim exposure
• Manage claims through action plans to timely and appropriate resolution
• Negotiate claim settlements within designated authority
• Calculate and assign reserves and manage reserve adequacy throughout the claim lifecycle
• Calculate and pay benefits, approve claim payments and adjustments, and settle claims within authority
• Prepare necessary state filings within statutory limits
• Manage litigation processes for timely and cost-effective resolution
• Coordinate vendor referrals for investigation and litigation management
• Apply cost containment techniques and strategic vendor partnerships
• Manage claim recoveries, including subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets
• Report claims to excess carriers and respond to requests for direction
• Communicate claim activity and processing with claimants and clients
• Maintain professional client relationships
• Ensure claim files are documented and claims coding is correct
• Refer cases to supervisors and management when appropriate

Workers Compensation Claims Examiner

• Guide customers through the claims process with ongoing guidance and support
• Investigate and process claims for vehicle and other property damage and moderate bodily injury
• Focus on accurate and efficient claims handling to prevent unnecessary expenses
• Provide high-quality customer service throughout the claims process
• Review and explain coverage details and claims procedures
• Set reserves for anticipated expenses
• Arrange vehicle inspections and rental authorizations
• Address customer inquiries and concerns to ensure satisfaction and retention
• Obtain information from involved parties and witnesses by phone, email, text, and letter
• Review law enforcement reports and gather additional evidence such as dash-cam and surveillance video
• Assess facts of loss and determine liability
• Identify and escalate high-risk files involving significant indemnity exposure or suspected fraud
• Analyze medical records and evaluate, negotiate, and settle moderate bodily injury claims
• Coordinate with legal counsel for represented claimants and unrepresented parties
• Serve as the primary customer contact and coordinate with other departments
• Collaborate with the team to support shared customers

Claims Specialist II

• Perform three-point contact on all new losses
• Apply heightened scrutiny to complex, catastrophic, and high-exposure cases
• Maintain detailed action plans and strategic resolution plans for assigned indemnity files
• Identify fraud indicators and refer cases to SIU
• Investigate and document complex claims involving multi-party liability, catastrophic injury, subrogation, or novel legal issues
• Lead medical management, direct specialists, coordinate life care planners, direct UR and IMEs, and manage PTD cases
• Partner with case managers to maximize early return to work
• Review medical bills for high-cost and unusual treatment patterns
• Lead permanent disability ratings and establish or adjust reserves on high-exposure files
• Ensure status reports comply with client reporting timelines and formats
• Direct litigation, select defense counsel, set strategy, retain experts, manage legal spend, and prepare for trial
• Lead mediations, settlement conferences, and arbitrations
• Make or recommend high-value settlement authority decisions with the Claims Supervisor and client
• Negotiate and finalize high-value settlements, including C&R and Stipulated Awards
• Manage multi-lien resolution and coordinate with lien counsel and CMS
• Pursue subrogation, contribution, and apportionment recovery
• Serve as technical backup for the Claims Supervisor
• Guide complex decisions, reserve adequacy, and escalated client issues
• Mentor Adjuster I and II colleagues and support unit-wide quality review
• Serve as senior point of contact for key client accounts
• Maintain client and carrier relationships
• Communicate proactively and transparently with stakeholders

Claims Adjuster III

• Manage a dedicated inventory of personal auto bodily injury claims
• Investigate liability, causation, and damages
• Review medical records and supporting injury documentation
• Establish and maintain appropriate reserves
• Negotiate settlements with claimants and attorneys
• Analyze liability and comparative negligence issues under California law
• Draft Large Loss Reports for high exposure claims
• Intake and summarize lawsuits
• Coordinate to retain defense counsel when necessary
• Handle and monitor litigated claims
• Attend mediations as needed
• Identify subrogation opportunities and SIU referrals when appropriate
• Maintain accurate claim documentation and regulatory compliance
• Own files from investigation through resolution

Bodily Injury Claims Adjuster

• Investigate, evaluate, and resolve property insurance claims.
• Adjust reserves and provide reserve recommendations.
• Enter claim transactions clearly and concisely.
• Examine claims inspected by independent adjusters, investigate questionable claims, verify coverage, and issue payments.
• Conduct daily diary reviews to ensure status letters are sent in accordance with Department of Insurance regulations.
• Pay and process claims within designated authority levels.
• Supervise independent adjusters for adherence to CFP IA Guidelines.
• Maintain compliance with Department of Insurance and company policies and procedures.
• Create accurate, complete correspondence and obtain missing information from policyholders and others.
• Negotiate settlements reflecting insured losses while protecting the insurer from invalid claims.
• Confer with Claims Management and legal counsel on litigated claims.
• Handle entire claims except inspection or specific coverages such as Personal Property or Fair Rental Value.
• Focus on claims over $300,000 in damages, while handling smaller claims when necessary.

Property Claims Examiner III

• Manage a dedicated inventory of personal auto bodily injury claims
• Investigate, evaluate, negotiate, and resolve bodily injury claims
• Investigate liability, causation, and damages
• Review medical records and supporting injury documentation
• Establish and maintain appropriate reserves
• Negotiate settlements with claimants and attorneys
• Analyze liability and comparative negligence issues under California law
• Draft Large Loss Reports for high exposure claims
• Intake and summarize lawsuits
• Coordinate to retain defense counsel when necessary
• Handle and monitor litigated claims
• Attend mediations as needed
• Identify subrogation opportunities and SIU referrals when appropriate
• Maintain accurate claim documentation and regulatory compliance
• Own files through the full claims cycle, from investigation through resolution

• Handle complex and high-profile Workers’ Compensation claims according to company standards
• Work closely with case managers and attorneys
• Manage subrogation, litigation, and potential claim recoveries
• Negotiate settlements
• Receive Workers’ Compensation claims and confirm policy coverage and claim acknowledgement
• Investigate claims, determine validity and compensability, and file necessary documentation with state agencies
• Establish reserves and authorize payments within reserving authority limits
• Develop and manage documented action plans with case and outcomes managers to reduce claim costs
• Coordinate early return-to-work efforts
• Report claims to excess carriers when applicable
• Communicate claim status with customers and claimants
• Follow client, carrier, state, and workplace safety requirements
• Develop and maintain professional customer relationships
• Participate in claims reviews as needed
• Perform additional duties as assigned

Senior Claims Specialist

• Create training presentations covering updates to policies, workers' compensation laws, and procedures
• Maintain a current and comprehensive action plan for all assigned indemnity claims
• Ensure timely completion of all claim file activities
• Oversee internal and external audits
• Review billing summaries

Workers' Compensation Claims Examiner

• Handle complex and high-profile Workers’ Compensation claims following company standards
• Receive Workers’ Compensation claims and confirm policy coverage and claim acknowledgement
• Investigate claims, determine validity and compensability, gather information, and file necessary documentation with state agencies
• Establish reserves and authorize payments within reserving authority limits
• Develop and manage documented action plans with case managers and outcomes managers to reduce claim costs
• Coordinate early return-to-work efforts
• Manage subrogation, litigation, and potential claim recoveries
• Report claims to excess carriers when applicable
• Communicate claim status with customers and claimants
• Adhere to client and carrier guidelines and participate in claims reviews
• Develop and maintain professional customer relationships
• Comply with applicable state rules and regulations and workplace safety requirements
• Perform additional duties as assigned