5,850 Claims Professionals jobs in the United States

Description

Marketing Statement:

Philadelphia Insurance Companies, a member of the Tokio Marine Group, designs, markets and underwrites commercial property/casualty and professional liability insurance products for select industries. We have been in operation since 1962 and are nationally recognized as a member of Ward's Top 50 and rated A+ by A.M.Best.

We are looking for a Claims Examiner to join our team!

Summary:

Investigate and analyze insurance claims to determine extent of Insurer's obligations. Settle claims with first and third party claimants in accordance with policy provisions and applicable law.

A typical day will include the following:

Travel may be required to attend customer service calls, mediations, and other legal proceedings.

Thoroughly understands coverages, policy terms and conditions for broad insurance areas, products or special contracts.

Communicates with all relevant parties and documents communication as well as results of investigation.

Evaluates each claim in light of facts; Affirm or deny coverage; investigate to establish proper reserves; and settles or denies claims in a fair and expeditious manner.

EEO Statement:

Tokio Marine Group of Companies (including, but not limited to the Philadelphia Insurance Companies, Tokio Marine America, Inc., TMNA Services, LLC, TM Claims Service, Inc. and First Insurance Company of Hawaii, Ltd.) is an Equal Opportunity Employer. In order to remain competitive we must attract, develop, motivate, and retain the most qualified employees regardless of age, color, race, religion, gender, disability, national or ethnic origin, family circumstances, life experiences, marital status, military status, sexual orientation and/or any other status protected by law.

Benefits:

We offer a comprehensive benefit package, which includes tuition reimbursement and a generous 401K match. Our rich history of outstanding results and growth allow us to focus our business plan on continued growth, new products, people development and internal career opportunities. If you enjoy working in a fast paced work environment with growth potential please apply online.

Additional information on Volunteer Benefits, Paid Vacation, Medical Benefits, Educational Incentives, Family Friendly Benefits and Investment Incentives can be found at

REQNUMBER:

• High School Diploma or equivalent.
• Three (3) or more years of chairside dental assistant experience or Certified Dental Assistant.
• Ability to data enter 4500 KSPH alpha & 5000 KSPH numeric.
• A thorough understanding of dental procedure codes and dental terminology.
• Must be able to determine correct procedure benefit and qualifications when reviewing documentation and/or dental radiographs that have been submitted with all claims and predeterminations.
• Ability to view radiographic images with accuracy.
• Working knowledge of Microsoft Word, Outlook, and Excel.

• Knowledge of the aQden claims processing system.
• A thorough understanding of DDOK's processing policies and how they apply to all contracts in force.
• Expanded chairside dental assisting duties that includes radiographic safety certification/working knowledge of radiographs.

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve.

Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies

Certified as a Great Place to Work®

Fortune Best Workplaces in Financial Services & Insurance

Claims Examiner

PRIMARY PURPOSE : To analyze and process complex auto and commercial transportation claims by reviewing coverage, completing investigations, determining liability and evaluating the scope of damages.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Processes complex auto commercial and personal line claims, including bodily injury and ensures claim files are properly documented and coded correctly.

• Responsible for litigation process on litigated claims.

• Coordinates vendor management, including the use of independent adjusters to assist the investigation of claims.

• Reports large claims to excess carrier(s).

• Develops and maintains action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution.

• Identifies and pursues subrogation and risk transfer opportunities; secures and disposes of salvage.

• Communicates claim action/processing with insured, client, and agent or broker when appropriate.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.

• Supports the organization's quality program(s).

• Travels as required.

QUALIFICATIONS

Education & Licensing

Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. Secure and maintain the State adjusting licenses as required for the position.

Experience

Five (5) years of claims management experience or equivalent combination of education and experience required to include in-depth knowledge of personal and commercial line auto policies, coverage's, principles, and laws.

Skills & Knowledge

• In-depth knowledge of personal and commercial line auto policies, coverage's, principles, and laws

• Knowledge of medical terminology for claim evaluation and Medicare compliance

• Knowledge of appropriate application for deductibles, sub-limits, SIR's, carrier and large deductible programs.

• Strong oral and written communication, including presentation skills

• PC literate, including Microsoft Office products

• Strong organizational skills

• Strong interpersonal skills

• Good negotiation skills

• Ability to work in a team environment

• Ability to meet or exceed Service Expectations

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

at any time.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.

Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see sedgwick.com

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve.

Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies

Certified as a Great Place to Work®

Fortune Best Workplaces in Financial Services & Insurance

Claims Examiner

PRIMARY PURPOSE : To analyze and process complex auto and commercial transportation claims by reviewing coverage, completing investigations, determining liability and evaluating the scope of damages.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Processes complex auto commercial and personal line claims, including bodily injury and ensures claim files are properly documented and coded correctly.

• Responsible for litigation process on litigated claims.

• Coordinates vendor management, including the use of independent adjusters to assist the investigation of claims.

• Reports large claims to excess carrier(s).

• Develops and maintains action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution.

• Identifies and pursues subrogation and risk transfer opportunities; secures and disposes of salvage.

• Communicates claim action/processing with insured, client, and agent or broker when appropriate.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.

• Supports the organization's quality program(s).

• Travels as required.

QUALIFICATIONS

Education & Licensing

Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred. Secure and maintain the State adjusting licenses as required for the position.

Experience

Five (5) years of claims management experience or equivalent combination of education and experience required to include in-depth knowledge of personal and commercial line auto policies, coverage's, principles, and laws.

Skills & Knowledge

• In-depth knowledge of personal and commercial line auto policies, coverage's, principles, and laws

• Knowledge of medical terminology for claim evaluation and Medicare compliance

• Knowledge of appropriate application for deductibles, sub-limits, SIR's, carrier and large deductible programs.

• Strong oral and written communication, including presentation skills

• PC literate, including Microsoft Office products

• Strong organizational skills

• Strong interpersonal skills

• Good negotiation skills

• Ability to work in a team environment

• Ability to meet or exceed Service Expectations

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

at any time.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.

Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see sedgwick.com

• Provides voice to voice contact within 24 hours of first report.
• Conducts timely coverage analysis and communication with insured based on application of policy information, facts or allegations of each case. Consults with Unit Manager on use of Claim Coverage Counsel.
• Investigates each claim through prompt contact with appropriate parties such as policyholders, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts to determine the extent of liability, damages, and contribution potential. Records necessary statements.
• Identifies resources for specific activities required to properly investigate claims such as Subro, Fire or Fraud investigators and to other experts. Requests through Unit Manager and coordinates the results of their efforts and findings.
• Verifies the nature and extent of injury or property damage by obtaining and reviewing appropriate records and damages documentation.
• Maintains effective diary management system to ensure that all claims are handled timely. Evaluates liability and damages exposure, and establishes proper indemnity and expense reserves, at required time intervals.
• Utilizes evaluation documentation tools in accordance with department guidelines.
• Responsible for prompt, cost effective, and proper disposition of all claims within delegated authority.
• Negotiate disposition of claims with insured's and claimants or their legal representatives. Recognizes and implements alternate means of resolution.
• Maintains and document claim file activities in accordance with established procedures.
• Attends depositions and mediations and all other legal proceedings, as needed.
• Protects organization's value by keeping information confidential.
• Maintains compliance with Claim Department's Best Practices.
• Provides quality customer service and ensures file quality
• Supports workload surges and/or Catastrophe operations as needed to include working significant overtime during designated CATs.
• Communicates with co-workers, management, clients, vendors, and others in a courteous and professional manner.
• Participates in special projects as assigned.
• Some overnight travel maybe required.
• Maintains the integrity of the company and products offered by complying with federal and state regulations as well as company policies and procedures.

• Associate's Degree required; Bachelor's Degree preferred. A combination of education and significant directly related experience may be considered in lieu of degree.
• 620 Licensure required.
• One to three years of experience processing claims; property and casualty segment preferred.
• Experience with Xactware products preferred.
• Demonstrated ability to research, conduct proactive investigations and negotiate successful resolutions.
• Proficiency with Microsoft Office products required; internet research tools preferred.
• Demonstrated customer service focus / superior customer service skills.
• Excellent communication skills and ability to interact on a professional level with internal and external personnel
• Results driven with strong problem solving and analytical skills.
• Ability to work independently in a fast paced environment; meets deadlines, and manages changing priorities effectively.
• Detail-oriented and exceptionally organized
• Collaborative partner; ability to contribute to a positive work environment.

Claims Examiner

Position Summary:

Investigates, evaluates, reserves, negotiates and settles assigned claims in accordance with Best Practices. Provides quality claim handling and superior customer service on assigned claims, while engaging in indemnity and expense management. Promptly manages claims by completing essential functions including contacts, investigation, damages development, evaluation, reserving, and disposition.

Responsibilities:

• Provides voice to voice contact within 24 hours of first report.
• Conducts timely coverage analysis and communication with insured based on application of policy information, facts or allegations of each case. Consults with Unit Manager on use of Claim Coverage Counsel.
• Investigates each claim through prompt contact with appropriate parties such as policyholders, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts to determine the extent of liability, damages, and contribution potential. Records necessary statements.
• Identifies resources for specific activities required to properly investigate claims such as Subro, Fire or Fraud investigators and to other experts. Requests through Unit Manager and coordinates the results of their efforts and findings.
• Verifies the nature and extent of injury or property damage by obtaining and reviewing appropriate records and damages documentation.
• Maintains effective diary management system to ensure that all claims are handled timely. Evaluates liability and damages exposure, and establishes proper indemnity and expense reserves, at required time intervals.
• Utilizes evaluation documentation tools in accordance with department guidelines.
• Responsible for prompt, cost effective, and proper disposition of all claims within delegated authority.
• Negotiate disposition of claims with insured's and claimants or their legal representatives. Recognizes and implements alternate means of resolution.
• Maintains and document claim file activities in accordance with established procedures.
• Attends depositions and mediations and all other legal proceedings, as needed.
• Protects organization's value by keeping information confidential.
• Maintains compliance with Claim Department's Best Practices.
• Provides quality customer service and ensures file quality
• Supports workload surges and/or Catastrophe operations as needed to include working significant overtime during designated CATs.
• Communicates with co-workers, management, clients, vendors, and others in a courteous and professional manner.
• Participates in special projects as assigned.
• Some overnight travel maybe required.
• Maintains the integrity of the company and products offered by complying with federal and state regulations as well as company policies and procedures.

• Associate's Degree required; Bachelor's Degree preferred. A combination of education and significant directly related experience may be considered in lieu of degree.
• Adjuster Licensure required.
• One to three years of experience processing claims; property and casualty segment preferred.
• Experience with Xactware products preferred.
• Demonstrated ability to research, conduct proactive investigations and negotiate successful resolutions.
• Proficiency with Microsoft Office products required; internet research tools preferred.
• Demonstrated customer service focus / superior customer service skills.
• Excellent communication skills and ability to interact on a professional level with internal and external personnel
• Results driven with strong problem solving and analytical skills.
• Ability to work independently in a fast paced environment; meets deadlines, and manages changing priorities effectively.
• Detail-oriented and exceptionally organized
• Collaborative partner; ability to contribute to a positive work environment.

• High School Diploma or equivalent.
• Three (3) or more years of chairside dental assistant experience or Certified Dental Assistant.
• Ability to data enter 4500 KSPH alpha & 5000 KSPH numeric.
• A thorough understanding of dental procedure codes and dental terminology.
• Must be able to determine correct procedure benefit and qualifications when reviewing documentation and/or dental radiographs that have been submitted with all claims and predeterminations.
• Ability to view radiographic images with accuracy.
• Working knowledge of Microsoft Word, Outlook, and Excel.

• Knowledge of the aQden claims processing system.
• A thorough understanding of DDOK's processing policies and how they apply to all contracts in force.
• Expanded chairside dental assisting duties that includes radiographic safety certification/working knowledge of radiographs.