Claims Adjuster Sample Job Descriptions

We seeking a highly motivated claims adjuster to join our team. Claims adjusters establish the business parameters of each claim by analyzing customer applications, company guidelines, laws/regulations, and cost-effectiveness. They also interpret computerized data systems to determine the scope of coverage available for losses that may occur within a policy or aggregate policy, identify covered properties, and assess risk. The responsibilities of claims adjusters include evaluating, investigating, and resolving claims according to company policy and state laws, establishing business parameters of every claim, communicating with customers throughout the claims process, and monitoring claims for possible fraud and misrepresentation. As a claims adjuster, you’ll be responsible for helping customers get back on the road after an accident. You’ll have the support of a collaborative team and ongoing coaching from leaders.

Typical duties and responsibilities

• Investigate insurance claims and determine if the insurance company should pay the claim
• Review medical records, police reports, and other documents related to the claim
• Determine the value of a claim and whether the insurance company should pay for damages, medical expenses, or other losses
• Prepare reports on their findings and make recommendations to the insurance company
• Negotiate with claimants to reach a settlement
• Represent the insurance company in court proceedings if a claim goes to trial

Education and experience

• A college degree is not required for this job, but some insurance companies may prefer to hire claims adjusters with a degree in business, economics, mathematics, or a related field
• Claims adjusters typically have at least three years of experience investigating insurance claims
• The ability to investigate each claim thoroughly and accurately
• They must be able to communicate effectively with claimants, witnesses, lawyers, insurance company representatives, doctors, and other professionals

Required skills and qualifications

• Thorough knowledge of insurance claims process
• Investigative skills
• Strong communication and negotiation skills
• Problem-solving skills
• Ability to work independently
• Ability to travel around the state

Preferred qualifications

• Bilingual abilities
• Familiarity with computers and software applications used in investigations, including databases and specific claims software programs
• Strong negotiation skills are important for this job
• They should have good problem-solving skills since claims can become very complicated
• Experience in the insurance industry is helpful, but not always necessary, as many claims adjusters come from a customer service background

The Claims Adjuster handles low to mid-range complexity claims that will consist of a direct investigation of the facts of loss, evaluation of coverages, damages, liability, and negotiation of claims to a proper conclusion. May be involved with litigated files for experience and developmental purposes.

Responsibilities

• Determines policy status and coverage; reviews appropriate policies and endorsements for coverage, limits, and deductibles; immediately notify manager of any claim that may be outside of the assigned scope of handling, level, or authority
• Makes prompt contact with policyholders, claimants, witnesses, and other parties involved in the loss to set expectations, develop an action plan, and perform an initial exposure assessment
• Conducts an investigation to determine coverage, liability, and damages, including recorded statements and coordination of field inspections or experts when necessary based on Department Best Practices
• Ensures regular and timely follow-up and brings claims to prompt and the appropriate conclusion while keeping the customer informed throughout the life cycle of the claim process
• Ability to scope and estimate real property, personal property, and time element damages using company-approved software applications
• Identifies any subrogation potential and liability exposures and consults with the supervisor
• Performs all claims-related functions with guided assistance and input from their supervisor
• Maintains electronic records that accurately and thoroughly document all file-handling activity
• May be called upon to perform additional duties as directed
• Reasonable and predictable attendance is required

Minimum education and experience

• 2 years or more of claim experience
• High school diploma or equivalent required. Post-secondary education preferred
• Current adjuster licensure or the ability to obtain within 90 days of hire
• Basic computer skills and Microsoft and Google applications preferred

Skills

• Professional oral and written communication skills are critical to the success of this position. All claims service must be handled with tact, diplomacy, and courtesy at all times
• Must be able to collaborate and develop strong team relationships with associates from within and outside the Claims Department
• Customer-centric with exceptional customer service skills

Job overview

ABC Company is looking for an Auto Claim Adjuster who will be responsible for evaluating and investigating policy coverage, liability, and damages while providing a high level of customer service when assisting customers and claimants in a timely manner with inquiries regarding the associated claim. The ideal candidate has about 1 to 2 years of prior auto claim adjusting experience, is able to communicate effectively, has excellent negotiation and investigative skills, is able to perform basic math calculations while managing time well to meet time-sensitive deadlines, is well organized, and displays critical thinking skills.

Responsibilities

• Evaluate and investigate policy coverage, liability, and damages in a timely manner following a set of general claim and statutory guidelines
• Assist customers and claimants with problems or questions regarding claims by phone or through written correspondence, while providing a high level of customer service
• Establish initial reserves for all potential exposures and adjust as appropriate throughout the claim
• Establish and maintain appropriate management of assigned inventory following company guidelines
• Conduct thorough investigations including but not limed to, obtaining necessary documents, forms, and witness statements, as well as conducting recorded statements
• Ensure timely assignment of appraisals using company-approved vendors, provide rental vehicles to claimants as needed, and able to determine accident-related damages
• Communicate with involved parties and negotiate appropriate settlements with claimants, insureds, and attorneys within approved payment authority
• Recognize recovery opportunities regarding total loss and salvage, as well as subrogation
• Other duties as assigned

Qualifications

• High School Diploma, GED or equivalent, required
• Bachelor’s degree in Business or another related field or equivalent work experience preferred
• INS or other insurance related courses preferred
• Proficient PC and Windows skills
• Proven ability to provide excellent customer service
• Ability to perform basic math calculations – addition, subtraction, multiplication, & division – as well as calculation of averages and percentages

Experience

• 1 – 2 years of auto claim adjusting experience or similar work experience
• Nonstandard Auto experience, a plus

Skills

• Effective written and verbal communication skills as well as negotiation and investigative skills
• Excellent time management, organizational, and critical thinking skills
• Superb attention to detail to ensure accuracy while meeting time-sensitive deadlines
• Strong ability to prepare and present accurate, reliable, and factual reports with recommendations to appropriate parties
• Ability to be flexible in a fast-paced environment as well as understand and follow oral and/or written policies, procedures, and instructions
• Discretion when handling confidential information
• Exhibit a comfort level working with key people at all levels within an organization

The Claims Adjuster performs duties to manage a caseload of low to moderately complex worker’s compensation claims. This consists of determining compensability, setting reserves, and approving payments, in accordance with industry/company Claims Best Practices. Analyzes and interprets statutes and regulations applicable to case facts in order to render appropriate legal and ethical decisions. Analyzes legal issues and directs legal strategy. Manages claims in a prompt and thorough manner from inception through closure. Aggressively negotiates the settlement of claims.

Responsibilities:

• With general management oversight, works within assigned authority limits on claims reflecting a low to moderate degree of technical complexity and severity
• Analyzes case facts, applies appropriate statutes and regulations, and identifies possible fraud and abuse, in determining compensability
• Analyzes case facts to establish timely and accurate case reserves. Requires knowledge of medical disabilities and related costs, as well as the judgment of the extent of disability. Applies knowledge of medical procedures, disabilities, and likely duration to determine an accurate estimate of claim cost
• Completes detailed settlement analysis and recommends appropriate settlement value, utilizing knowledge of appropriate Worker’s Compensation insurance principles and laws, subrogation recoveries, offsets and deductions, claim and disability duration, and cost containment principles, including medical management practices, Social Security, and Medicare application procedure as applicable
• Ensures quality medical management by applying appropriate medical concepts, and by interpreting and applying appropriate statutes and regulations. Requires independent judgment to render accurate decisions
• Proactively manages claim litigation process. Manages legal issues that can be adjudicated without the use of a defense attorney. Directs legal strategy and participates in the preparation of the case for litigation. Provides testimony at hearings as needed
• Analyze physician reports for content and accuracy to ensure prompt and appropriate processing of medical and indemnity benefits
• Evaluates, prepares, and manages cases of possible permanent partial disability
• Manages dedicated accounts as assigned. Participates in telephonic claim reviews
• Other duties may be assigned

Job requirements:

• Excellent written and oral communication, listening, interpersonal, customer service, and telephone skills
• Proficient in the use and knowledge of MS Office software, with the ability to type at a minimum of 35 wpm
• Demonstrated knowledge of Workers’ Compensation laws and ability to adhere to statutes, regulations, and company policies and practices, as well as related claim management procedures/protocols. Comprehensive knowledge of AMA Guides to the Evaluation of Permanent Impairment and medical terminology
• Self-motivated with excellent analytical, problem-solving, and decision-making skills and the ability to deal professionally with people in stressful situations. Ability to maintain confidentiality. Conduct business at all times with the highest standards of personal, professional, and ethical conduct
• If State Certification is required, one must meet requirements and obtain certification within the state-mandated time frame
• Must have High School Diploma or GED equivalent
• Must possess 2-5 years of related claims experience
• Ability to participate in job-related internal and external training and pass any tests within the set guidelines
• Bachelor’s degree or equivalent business experience preferred
• WCCP certification preferred
• Current Experienced Claims Adjuster Designation preferred
• Working knowledge of an imaged claims environment preferred
• Bilingual in English and Spanish preferred
• An equivalent combination of education and experience may be substituted for the requirements listed above