Senior Claims Specialist - Defined Staffing Solutions
Jurupa Valley, CA 91752
About the Job
Claims Specialist
The Claims Specialist is responsible for evaluating, processing, and managing liability, property, auto, general liability, and employment claims in compliance with state regulations. This role requires documenting activities, conveying information regarding claims or benefits, and providing testimony in disputes. The ideal candidate will exercise discretion, independent judgment, and critical thinking while delivering exemplary customer service.
Primary Responsibilities:
- Claims Management: Evaluate and manage liability, property, auto, general liability, and employment claims in compliance with state regulations.
- Claims Adjudication: Handle auto and general liability claims for Pavement Recycling Systems and all associated entities, determining claim validity, closure, and compliance with legal requirements and state statutes.
- Liability Analysis: Analyze liability exposure for branches, ensuring appropriate actions are taken.
- Legal Proceedings: Attend legal hearings, settlement conferences, and mediations, providing testimony and monitoring the proceedings.
- Claims Evaluation: Establish eligibility and course of action for auto and general liability claims.
- Record Keeping: Maintain accurate claims files and records, ensuring compliance with policies and mandated legal requirements.
- Third-Party Management: Oversee third-party providers (e.g., litigation on complex cases) to ensure claims are handled in accordance with state legal regulations.
- Reporting: Prepare statistical summaries, evaluations, and reports; provide oral presentations documenting claims activities.
- Customer Interaction: Respond to inquiries from claimants and involved personnel regarding claim status, subrogation activities, and other issues, fostering clear communication among all parties.
- Claims Review: Provide timely, balanced, and accurate claims reviews, documentation, and decisions in a fast-paced, deadline-driven environment while adhering to state and insurance department regulations.
- Customer Communication: Act as the company’s representative by proactively communicating with claimants, customers, and their representatives, demonstrating empathy, active listening, and clarity regarding the claims process, benefits, and policy provisions.
- Documentation: Document conversations within claim files in a timely manner, using professional writing skills and sufficient detail.
- Stakeholder Interaction: Interact with claimants, healthcare providers, attorneys, brokers, and family members throughout the claims evaluation process.
- Policy Analysis: Compile file documentation and correspondence, requiring extensive policy analysis and attention to factual detail.
- Claims Investigation: Analyze information to determine if additional data is needed to make reasonable and logical claims decisions.
- Collaboration: Work with external and internal resources, such as physicians, attorneys, and vocational consultants, to gather relevant data for well-reasoned claim decisions.
- Inconsistency Resolution: Identify, clarify, and reconcile inconsistencies during claim evaluations, working with underwriting and Fraud Waste and Abuse teams as needed.
- Benefit Calculation: Identify offsets and proficiently calculate monthly benefits due after the elimination period, including COLA, Social Security offsets, residual disability, and non-routine payments.
- Complaint Resolution: Address and resolve escalated customer complaints in a timely and thorough manner.
- Additional Duties: Perform other tasks as assigned.
Qualifications:
- Time Management: Proven ability to manage multiple tasks with tight deadlines.
- Attention to Detail: Highly detail-oriented with strong organizational skills.
- Judgment & Decision Making: Prior experience with independent judgment, critical thinking, and effective decision-making.
- Communication Skills: Excellent written and oral communication skills, paired with strong listening abilities.
- Team Player: Highly motivated, with a demonstrated passion for excellence and initiative.
- Problem-Solving: Strong analytical skills with the ability to handle complex situations and manage risks effectively.
- Customer Service: Outstanding customer service skills proven through interactions with both internal and external stakeholders.
- Technology Skills: Knowledge of Microsoft Outlook, Word, and Excel; ability to manage multiple systems and technology sources.
Education and Experience:
- Education: Bachelor’s degree or a combination of education and relevant experience.
- Experience: 7+ years of experience handling Workers’ Compensation, liability, property, auto, or general liability claims.
- Legal Knowledge: Prior experience in damages, investigations, and contractual disputes, claims, and litigation.
- Licensing: Valid driver’s license with an acceptable driving record.
- Legal Understanding: Multi-jurisdictional knowledge of legal issues is required.
Why Join Us:
- Retirement Benefits: ESOP Retirement Benefits after one year of service, with typical company contributions ranging from 10% to 15% of your annual salary.
- 401K: Retirement benefits available to all non-union employees.
- Health Coverage: Comprehensive Health, Dental, and Vision coverage, along with supplemental health insurance options.
- Paid Time Off: Generous PTO and Holiday Pay.
- Career Advancement: Opportunities for growth and professional development within the company.
- On-the-Job Training: Ongoing training and development provided to all employees.
- Industry Leader: Work for an innovative company recognized as an industry leader in multiple disciplines and markets.
Physical Requirements:
- Physical Demands: Regularly required to use hands to finger, handle, or feel objects, tools, or controls and frequently required to stand, walk, talk, and hear.
- Mobility: Regularly required to sit, climb, balance, stoop, kneel, crouch, and crawl.
- Lifting Requirements: Must be able to lift and/or move up to 10 pounds frequently and up to 25 pounds occasionally.
- Vision Requirements: Specific vision abilities required include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
We are an equal opportunity employer and provide equal consideration for employment to all qualified applicants without regard to age, race, color, religion, creed, sex, sexual orientation, gender identity, national origin, marital status, disability, veteran status, or any other characteristic protected by federal, state, or local law.
Source : Defined Staffing Solutions
