Claims Examiner jobs in Utica, NY

The No Fault Examiner is responsible for the prompt and fair settlement of no-fault claims. Managing the claim process, including coverage verification, investigation, evaluation, and disposition of the claim in compliance with applicable insurance regulations and NYCM’s best practices. They assess and ensure the customer’s needs and expectations of the claim process are met with empathy and professionalism.

Duties & Responsibilities:

• Verify policy coverage: Basic PIP, APIP, OBEL and Med Pay.
• Determine eligibility, exclusions, Workers Compensation coverage, out of state coverage and all subrogation recovery opportunities.
• Accurately reserve claims for potential exposure based on injuries sustained.
• Identify fraud indicator and discuss with EFW and refer applicable files to SIU.
• Conduct a thorough investigation of claims, gathering all necessary information for proper claims resolution.
• Process payments and denials in accordance with investigation, policy coverage and regulations.
• Manage cycle times and customer experience through comprehensive file review and timely processing.
• Determine loss of earnings reimbursement claims.
• Assess the need for independent medical examination using IME criteria and individual claim analysis.
• Testify in court.
• Effectively communicate and establish connections with the customers during the claim process.
• Professional handling of incoming and outgoing customer phone calls.
• Professional written communications such as emails, requests for information or coverage letters.
• Guide customers, including claimants, through the claim process, ensuring that they are informed at all stages.
• Manage customer concerns/complaints and independently develop and execute a plan to remedy the situation for a better customer experience.
• Manage daily workload to stay current on new and existing claim files.
• Maintain accurate payment worksheets.
• Receive and maintain claim information.
• Maintain current knowledge base of existing and emerging best practices, regulations, standards, guidance documents, and internal procedures.
• Participate in insurance related education to stay up to date on relevant fraud trends.
• Additional duties as assigned.

Requirements:

• High School Diploma
• 3 years claims or industry related experience

Qualifications & Skills:

• Full working knowledge and understanding of basic insurance principals and policies, claims procedures, regulations, and best practices.
• Good personal computer skills including electronic mail, and record keeping, claims systems and Mitchell DecisionPoint.
• Understanding of medical injuries and how they relate to claim file management.
• Strong interpersonal skills, with the ability to work within a team or independently without direct supervision.
• Willingness and ability to engage in authentic conversations.
• Good written and verbal communication skills and active listening.
• Organized; detail oriented and ability to multi-task and prioritize.
• Strong evaluation and decision-making abilities.
• Ability to handle stress professionally, calmly, and effectively.
• Critical thinking.
• Positive and professional attitude.
• Willingness to pursue professional development.

Payband 3 / 37.5 hours per week

Salary: $31,470-$54,796