New York Personal Injury Protection Adjuster - Remote
About The Position
Under general supervision, this job is responsible for handling the medical portion of auto accident claims for the insured or other injured parties found to be eligible under a personal injury protection and/or medical payment benefits where the policy limits or exposure to the company is limited and occasionally when the policy limits or exposure to the company is moderate. This individual determines coverage and assesses medical claims, evaluates medical bills, and initiates or reviews potential fraud investigations as warranted. The individual explains coverage, negotiates and settles claims, and follows up with the customer on continuing treatments while delivering compassionate service that is fast, fair, and easy, to ensure customer retention. At this level, the individual typically negotiates and settles moderately complex claims, such as claims in less regulated and occasionally moderately regulated states (or in some situations more complex claims with guidance as needed). The individual is capable of working independently, prioritizing the individual's own responsibilities, and managing the individual's own workload. The individual also consistently meets band level behaviors, production, quality, and/or customer service goals.
Requirements
- Strong knowledge of insurance policies, particularly personal injury protection coverage and relevant regulations
- Ability to evaluate claims by reviewing accident reports, medical records, and other documents
- Excellent communication skills for effectively interacting with claimants, medical providers, and other stakeholders
- Strong investigative and research skills to gather information and uncover relevant facts
- Analytical and critical thinking abilities to assess medical records, calculate reimbursement amounts, and make informed decisions
- Negotiation skills to resolve disputes, reach settlements, and establish payment plans
- Effective time management and organizational skills to handle multiple claims and meet deadlines
- Commitment to providing excellent customer service, showing empathy and professionalism
- Basic understanding of relevant laws and regulations related to insurance and personal injury cases
- Business Communications
- Critical Thinking
- Curious Mindset
- Customer Handling
- Fraud Investigations
- Information Collection
- Time Management
- Time Prioritization
Responsibilities
- Makes and maintains a connection with the customer by understanding and meeting their needs; serves the customer with empathy; and follows up to ensure that customer needs have been met
- Researches and responds to moderately complex customer communications, concerns, conflicts, or issues
- Summarizes documents and enters claim system notes
- Documents a claim file with notes, evaluations, and decision-making process
- Processes medical bills and recognizes medical management opportunities
- Assesses medical/physical condition and prior injuries of claimant, and obtains and analyzes medical bills, wage loss reviews, home service or attendant care, mileage payments, and other related claims to determine reasonableness of charges and relation of injuries to accident, and to ensure compliance with fee schedules, and detect duplicate billing
- Conducts first party file processing/fact gathering, including interviewing claimant, witnesses, medical providers, etc
- Evaluates medical records and treatment plan of claimant and determines if continued treatment is reasonable
- Sets up IME and reviews results
- Investigates, reviews, and accepts or rejects moderately complex coverage and other potential coverage; and investigates coverage denial questions
- Determines appropriate benefit and negotiates and settles moderately complex claims, including resolution of moderately complex usual and customary billings
- Monitors treatment and benefit payments for excessive, unreasonable, or abusive claims
- Handles specialized claims
- May participate in one or more moderately complex special assignments
- May serve as a committee team lead for smaller projects or as a committee team member on medium projects
- Reviews subpoenas and non-complex demands (e.g., Florida demands)
- May serve as an agent advocate
- May prepare and negotiate moderately complex subrogation issues or arbitrations
Benefits
- Time off
- Healthcare
- Retirement
- Competitive pay
- Support for continuous development and career advancement
- Flexibility in scheduling
- Time off policy that helps support your work/life balance
- Initial and ongoing training
- 401K/pension
- Education reimbursement
- Programs to help you balance work with the rest of your life
- Comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse
- Monthly connectivity reimbursement to help offset internet costs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
