索赔代表 II - 机动车
Claim Representative II - Auto
职位描述
这是理赔处理职业路径中的中级职位，负责管理密歇根无过失个人伤害保险（PIP）索赔案件，这些案件复杂程度中等至高。理赔代表II负责调查和处理诉讼和非诉讼的PIP索赔，独立判断保险范围分析、可赔偿性确定、风险评估和索赔解决。该职位需要深入了解密歇根无过失法律，包括优先顺序调查、保险范围验证、伤害因果关系分析和诉讼管理。理赔代表II经常与被保险人、索赔人、医疗提供者、律师和内部业务合作伙伴合作，以确保及时、准确和合规的理赔处理。
职责/任务：
- 通过彻底调查索赔，确定根据密歇根分配索赔计划和密歇根无过失法案是否具有可赔偿性。
- 确定报告的伤害与事件之间的因果关系，以确保适当支付福利。
- 根据索赔的特征，在给定的权限范围内，基于预期的财务风险建立及时且适当的准备金。
- 记录可能进行代位追偿的索赔细节，包括潜在追偿金额。
- 直接管理与所报伤害相关的密歇根无过失索赔的医疗账单。根据治疗方案和显示治疗与伤害之间关系的医疗支持，批准付款。
- 在索赔解决后结案，以满足内部和客户指令的绩效标准，同时遵守州立法以避免处罚并控制费用。
- 在授权范围内尽早与律师或受伤方协商和解，以使案件最终结案。
- 与经理密切合作处理复杂案件或超出和解/准备金权限的案件。
- 管理外部供应商以确保成本控制。
- 建立并维护与所有内部和外部客户的有效工作关系。
- 及时了解密歇根无过失和密歇根分配索赔计划法规、判例法以及康复工作的进展，以便准确解释和应用相关法律。
额外职责/任务：
- 处理复杂索赔和灾难性索赔
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SUMMARY
This is the intermediate level of the claims handling career path responsible for managing a caseload of Michigan No-Fault Personal Injury Protection (PIP) claims of moderate to high complexity. The Claim Representative II investigates and administers both litigated and non-litigated PIP claims, exercising independent judgment in coverage analysis, compensability determinations, exposure evaluation, and claim resolution. The position requires thorough knowledge of Michigan No-Fault law, including order of priority investigations, coverage verification, injury causation analysis, and litigation management. The Claim Representative II collaborates regularly with insureds, claimants, healthcare providers, attorneys, and internal business partners to ensure timely, accurate, and compliant claim handling.
RESPONSIBILITIES/TASKS:
- Determines compensability under Michigan Assigned Claims Plan and the Michigan No Fault Act by a thorough investigation of the claim.
- Determines causal relationship between the reported injury and the incident to ensure appropriate payment of benefits.
- Establishes timely and appropriate reserves based on the profile of the claim within given authority based on anticipated financial exposure.
- Documents specifics of claims with potential for subrogation recovery, including amount of potential recovery monies.
- Manages medical bills for Michigan No Fault claims directly associated with the claimed injury. Approves payment based on knowledge of the treatment plan and medical support showing relationship of treatment to the injury.
- Concludes and closes files following resolution of claims to meet internal and client directives performance standards while complying with state legislation to avoid penalties and manage expenses.
- Negotiates settlements with attorneys or injured parties within given authority at the earliest possible point to bring cases to final disposition.
- Works closely with manager on complex files or files above settlement/reserve authority.
- Manages outside vendors to ensure cost containment efforts.
- Establishes and maintains effective working relationships with all internal and external customers.
- Stays abreast of changes in Michigan No-Fault and Michigan Assigned Claims Plan statutes and, case law and rehabilitation efforts/advancements in order to accurately interpret and apply relevant laws.
ADDITIONAL RESPONSIBILITIES/TASKS:
- Administers complex claims and catastrophic exposures within authority, including claims from dedicated large accounts.
- Exercises independent judgment to settle cases prior to mediation or litigation.
- Actively participates in agent/client relationship management.
- Assists in mentoring team members.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
EMPLOYMENT QUALIFICATIONS
EDUCATION OR EQUIVALENT EXPERIENCE:
Bachelor’s degree in a related field. Relevant combination of education and MACP claim handling experience may be considered, in lieu of degree. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
EXPERIENCE:
Three years’ experience in handling MCAP claims in an environment which provides the necessary skills, knowledge and abilities, such as experience in reviewing, investigating and closing MACP claims. Experience handling claims in multiple jurisdictions preferred. Bilingual skills preferred.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
- Ability and proficiency in the use of computers and company standard software specific to position.
- Knowledge of medical and legal terminology related to the work.
- Knowledge and handing of Michigan Assigned Claims Plan and Michigan Automobile No Fault and regulations, including jurisdictional laws.
- Effective oral and written communication skills.
- Effective customer service skills.
- Ability to negotiate, build consensus and resolve conflict.
- Ability to manage multiple priorities and meet established deadlines.
- Attention to detail and analytical skills.
- Ability to work independently as well as within a team.
- Ability to make independent decisions.
- Ability to solve complex problems.
WORKING CONDITIONS:
Work is performed in an office setting with no unusual hazards.
The qualifications listed above are intended to represent the minimal skills and experience levels associated with performing the duties and responsibilities contained in this position description. The qualifications should not be viewed as absolute standards, but as general guidelines that should be considered with other position-related criteria.
Pay Range - Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market, and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $56,700 - $94,900.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.
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Originally posted on Himalayas