Commercial Auto, PIP Claims Examiner II

POSITION SUMMARY: Responsibilities include but are not limited to:

DUTIES AND RESPONSIBILITIES:

• Review PIP 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.


• Negotiate with attorneys to settle PIP Suits and Arbitrations


• 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).

EQUIPMENT OPERATED/USED: Computer, 10-key, printer, copier, fax/scanner machine and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING:     Appropriate office attire.  Must have a functional office or workspace with reliable direct ethernet internet connection,