Claims Specialist

• Analyze and research claim issues of moderate to complex difficulty
• Comprehend complicated workflows, policy certificates, and policy provisions
• Review and apply policy provisions in processing claims received
• Request and obtain necessary documents for claim processing and schedule documentation follow-ups
• Release accurate benefit payments in accordance with CBP policy, industry standards, and applicable TPA or SLA agreements
• Properly document required information and follow-up information in the claim system
• Receive inbound calls within assigned queues and/or as overflow for the CSR team

Accident and Health Claims Examiner

• Adjust complex auto and homeowner bodily injury claims, UM/UIM claims, and small business claims
• Confirm coverage and make coverage decisions on complex claims
• Investigate loss details and determine legal liability
• Evaluate, negotiate, and adjudicate claims within authority guidelines
• Document claims accurately to support appropriate outcomes
• Prioritize and manage assigned claims workload
• Keep members and involved parties informed through timely claims status updates
• Collaborate with team members to resolve issues and identify matters for escalation
• Partner with or direct vendors and internal business partners to facilitate timely claims resolution
• Serve as a resource for team members on complex claims
• Deliver concierge-level, best-in-class member service through expectation-setting, proactive phone and written communication, advice, and empathy
• Handle higher-complexity claims and additional work as needed
• Identify, measure, monitor, and control business risks according to risk and compliance policies and procedures

Injury Claims Examiner – East Region

• Analyze and process complex or technically difficult general liability claims by investigating and gathering information to determine claim exposure
• Manage claims through well-developed action plans to timely and appropriate resolution
• Manage the litigation process and ensure timely, cost-effective claims resolution
• Coordinate vendor referrals for additional investigation and/or litigation management
• Lead team meetings and assign accountability for follow-up items
• Gather compliance and claims processing information for team meetings
• Assist in interviews of adjusters and clerical staff and provide feedback to the hiring manager
• Support the team lead with monthly reviews of adjuster workloads, identify trends, and suggest adjustments
• May supervise up to three direct reports
• Administer company personnel policies and follow staffing standards and training recommendations
• Interview, hire, establish performance development plans, and conduct performance discussions
• Provide support, guidance, leadership, and motivation to promote maximum performance

Claims Examiner – Workers Compensation, FL

• Analyze and process complex or technically difficult general liability claims
• Investigate and gather information to determine claim exposure
• Manage claims through action plans to timely and appropriate resolution
• Assess liability and resolve claims within evaluation
• Negotiate claim settlements within designated authority
• Calculate and assign timely and appropriate reserves and manage reserve adequacy
• 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 direction requests
• Communicate claim activity and processing with claimants and clients
• Maintain professional client relationships
• Ensure claim files are documented and claim coding is correct
• Refer cases to supervisors and management as appropriate
• Support quality programs and perform other assigned duties
• Travel as required

Claims Examiner – Liability, IA, TX, or FL Required

• Review and adjudicate long-term care claims and policy provisions for payment or denial
• Process payment or issue denial for invoices pertaining to long-term care claims
• Identify, analyze, and apply long-term care claim product features and applicable policy benefits
• Meet or exceed management-approved production and quality targets
• Respond accurately, timely, and professionally to external and internal correspondence regarding benefits, eligibility, claim payments, denials, and explanations of benefits
• Handle inbound claim calls
• Maintain working knowledge of company services and claims, administrative, and imaging software systems
• Operate in compliance with HIPAA, fraud, confidentiality, and private health information guidelines
• Perform other duties as assigned

Claims Examiner

• Review documents, estimates, policy forms, and determine if and how coverage applies to submitted claims
• Authorize payment within scope of authority, resolve claims cost-effectively, and ensure timely issuance of disbursements
• Refer claims to carriers as needed
• Write coverage letters detailing coverage positions
• Interact professionally with insurance carriers, internal and external customers, and departmental staff
• For liability claims, coordinate with the carrier and assigned adjusting firms
• Review property claims for timely and accurate compliance, documentation, adjustment, and indemnity approval

• Review and assess proposed product performance claims against industry, regulatory, and company requirements
• Validate claimed product features and benefits by analyzing clinical studies, technical data sheets, and testing reports
• Guide vendors on required claim support and ensure approved claims align with substantiation provided
• Partner with Legal to maintain compliance with FTC requirements, truth-in-advertising standards, and customer experience expectations
• Provide technical guidance, training, and root-cause-driven CAPA support
• Track vendor and process performance to identify trends and drive corrective actions and QA process improvements
• Support QVC and HSN in evaluating and determining approval or rejection of product performance claims

Claims Specialist jobs in Florida

Accident and Health Claims Examiner

Injury Claims Examiner – East Region

Claims Examiner – Workers Compensation, FL

Claims Examiner – Liability, IA, TX, or FL Required

Claims Examiner

Claims Examiner

QA Performance Claims Specialist