Evaluate auto claims involving injured parties and manage first party medical treatment to determine eligibility under a personal injury protection and/or medical payment benefits
Reviews claims to determine the nature of the medical loss and provides explanation of coverage
Researches policy contract and interprets policy language to make coverage decisions based on 1st party medical coverage
Assesses medical treatment, evaluates medical bills, and initiates or reviews potential fraud investigations
Interprets medical records regarding injuries and addresses ongoing and continuous treatment for claimant
Identifies claim exposures and establishes reserves or adjust reserves accordingly on assigned files
Ensures claim files are properly documented and correctly coded based on the policy
Documents all claim activity and workflow accurately throughout the life of the claim in accordance with standard operating procedures
Provides effective and timely communication to client, claimants, medical providers, attorney offices, and vendors
Negotiates resolution of claims and makes payments within authority

Bachelor's degree from an accredited college or university preferred
State adjuster licenses required
Three (3) years of Personal Injury Protection (PIP), medical payment and/or workers compensation or equivalent combination of education and experience, nursing experience a plus
Knowledge of medical terminology and appropriate application of deductibles and limits
Familiarity with Bodily Injury (BI)/Casualty adjusting
Oral and written communication skills
Detailed oriented
PC literate, including Microsoft Office products
Strong negotiation skills
Good interpersonal and customer skills
Good organization skills
Good time management skills with the ability to multi-task
Ability to work independently and in a team environment
Ability to meet or exceed Performance Competencies

Claims Representative, Auto, PIP

Key skills