• Resolve claims and respond to inquiries involving members, agents, and vendors • Handle complex bodily injury and coverage claims • Manage litigated files and subrogation on closed files • Make appropriate coverage determinations and handle claims within prescribed authority levels • Manage vendor activities and prepare reports for meetings

• Responsible for the direct handling of PIP claims with some secondary responsibility for light to moderate Auto Bodily Injury Claims. • Address all claim issues by gathering information necessary to make informed and responsible decisions to bring these PIP claims to an appropriate resolution. • Ensure compliance with established claim handling guidelines regarding coverage, investigation, liability, damages, evaluation, and resolution. • Evaluate the nature and severity of PIP claims; review medical bills, lost wages, and other expenses to determine if the insured is eligible for coverage based on policy terms, state regulations, and the specifics of each claim. • Negotiate by developing a PIP settlement strategy and negotiating with the claimant, their employer, and/or legal counsel. • Keep track of your PIP log to ensure proper medical payments are made by the coverage available. • Utilize critical thinking and solid judgment to solve problems, make decisions and resolve issues inherent in handling PIP and Bodily Injury losses, as well as plan and organize activities throughout the claim’s management process. • Draft declination, Reservation of Rights and other coverage letters. • Establish reserves pursuant to established reserving protocols and reserve authority procedures. • Investigate commercial claims, while following corporate standards and guidelines. • Communicate with policyholders, and third-party claimants to reach fair and reasonable settlements. • Review and negotiate material damage appraisals with mechanics, repair shops or similar vendors.

• Analyze and process a variety of complex medical claims in accordance with program policies and procedures, ensuring accuracy and compliance. • Analyze claims and adjudicate them according to program guidelines, employing critical thinking to navigate complex scenarios. • Ensure claims are processed promptly to meet client standards and regulatory requirements, employing effective problem-solving skills to address any barriers. • Proactively resolve claim discrepancies and issues by collaborating with other departments, utilizing analytical skills to identify root causes and implement solutions. • Uphold the confidentiality of patient records and company information as per HIPAA regulations. • Maintain thorough records of claims processed, denied, or requiring further investigation, ensuring transparency and traceability. • Analyze and report on trends in claim issues or irregularities to management, contributing to process improvement initiatives; Assists Team Leads with reporting. • Engage in audits and compliance reviews to ensure adherence to internal and external regulations, using critical thinking to evaluate processes. • Mentors and trains new claims processors as needed.

• Manage the insurance claims process • Provide customer service to clients • Analyze and approve claims that cannot be adjudicated • Determine coverage and applies medical necessity guidelines • Identify and clarify any discrepancies to assist in the adjudication process • Ensure accurate and timely processing of rejected claims • Work directly with third party payers for claim resolution • Communicate with facilities on claim issues • Resolve discrepancies and secure proper reimbursement • Follow federal and state regulations • Adhere to company policies and procedures • Follow HIPPA guidelines and regulations