Commercial Auto No Fault / PIP Claims Examiner II

Tristar Insurance•Philadelphia, PA

10d•$65,000 - $72,000•Hybrid

About The Position

Responsibilities include but are not limited to: Review PIP/ No Fault coverages and/or identify coverage issues and investigate and analyze the loss event, the injury and other relevant information to make a determination as to coverage and course of action. Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information. Concisely and accurately document all actions taken throughout the course of the claim. Investigate prior losses and other information on file and orders reports as needed. Evaluate claims for fraud indicators and potential underwriting issues and process appropriate referrals. Conduct activities in compliance with state and company regulations and guidelines. Render final coverage determination within regulatory guidelines: Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information (Reservation of Right letter, etc.) Need to recognize prolonged or excessive treatment and promptly schedule an IME with the appropriate medical profession via an approved company vendor. Generates and sends appropriate forms to insured/claimant for completion. Processes claims payments. Completes all necessary forms, logs documents into the system, and routes them to the appropriate parties. Need to be an effective team player. Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews and/or IMEs, when required, communicate determinations to appropriate parties within 3 business days. Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits. Establish adequate medical and non-medical benefits reserves for the life of the claim and adjust reserves, if needed. Calculate and issue non-medical benefits (wages, essential services, death benefits).

Requirements

3-5 years of handling Pennsylvania, Auto No Fault /PIP claims
Ability to multi-task and prioritize the tasks at hand.
Ability to perform data entry, email, calendar management, Word and Excel functions.
Excellent verbal and written communication skills.
Strong interpersonal and customer service skills
High school diploma or GED required
A minimum of 3 - 5 years Pennsylvania, Commercial Auto No Fault / PIP casualty related experience; or equivalent combination of advanced education and experience.
At least 3 - 5 years Pennsylvania, Commercial Auto No Fault / PIP liability claims experience required.
Demonstrated advanced analytical, decision making and negotiation skills.
Computer proficiency.
Ability to communicate effectively and clearly, both orally and in writing.
Ability to manage relationships in a fast-paced environment, while demonstrating problem solving and decision-making skills to work with customers.
Good analytical abilities to review, exercise judgment and evaluate claims in order to make sound decisions with a minimal amount of supervision.
Excellent customer service skills.
An understanding of the litigation process and case valuation in multiple jurisdictions.
Ability to carry out detailed written or verbal instructions, ability to respond to requests effectively and efficiently and exhibit good common sense.
An ability to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision.
Time management skills, organizational skills and ability to prioritize issues and tasks.
Ability to effectively operate computer equipment and applications.
Independence, flexibility and creativity.
Logical or scientific thinking to solve problems; several abstract and concrete variables.
Arithmetic calculations involving fractions, decimals, and percentages.
Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.
Near vision: clarity of vision at 20 inches or less
Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.
Grasping: Applying pressure to an object with the fingers and palm.
Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts.
Repetitive Motion: Substantial movements (motions) of the wrists, hands, and/or fingers.

Nice To Haves

Bachelor’s degree in related field (preferred)
Additional experience handling auto liability claims is a plus.
Ability to perform data entry, email, calendar management, Word and Excel functions.

Responsibilities

Review PIP/ No Fault coverages and/or identify coverage issues and investigate and analyze the loss event, the injury and other relevant information to make a determination as to coverage and course of action.
Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information.
Concisely and accurately document all actions taken throughout the course of the claim.
Investigate prior losses and other information on file and orders reports as needed.
Evaluate claims for fraud indicators and potential underwriting issues and process appropriate referrals.
Conduct activities in compliance with state and company regulations and guidelines.
Render final coverage determination within regulatory guidelines.
Recognize prolonged or excessive treatment and promptly schedule an IME with the appropriate medical profession via an approved company vendor.
Generate and send appropriate forms to insured/claimant for completion.
Process claims payments.
Complete all necessary forms, log documents into the system, and route them to the appropriate parties.
Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews and/or IMEs, when required, communicate determinations to appropriate parties within 3 business days.
Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits.
Establish adequate medical and non-medical benefits reserves for the life of the claim and adjust reserves, if needed.
Calculate and issue non-medical benefits (wages, essential services, death benefits).