Claims Examiner

General Description of Scope of Responsibilities

The Claim Examiner assists in achieving the organization’s mission and the Claims Department’s vision and goals by managing the intake, investigation, evaluation, and disposition of claim events, occurrences, claims, or suits presented on behalf of or against insureds.

• Receive, collect, and synthesize information to determine next actions for reported or discovered claim events.
• Determine when coverage or coverage-related services attach to a claim event.
• Identify the rights, duties, and responsibilities of parties to whom the organization owes a duty or from whom a duty is owed.
• Create and execute a management plan for each claim event, acting in good faith on all applicable duties.
• Establish and maintain accurate records of information received, decisions made, actions taken, reserves and payments, communications, course of handling, internal information controls, and ultimate disposition.
• Estimate and, when appropriate, re-estimate likely loss and expense for each claim event in a timely, accurate manner.
• Provide effective, appropriate communication to relevant internal and external stakeholders.
• Share timely, meaningful, and accurate claim information with internal partners and, as appropriate, with external parties such as legal counsel, investigators, adjusters, insureds, claimants, and reinsurers while protecting privileged, confidential, and proprietary information.
• Participate in peer review to evaluate the quality, efficiency, effectiveness, and appropriateness of processes, procedures, systems, and guidelines affecting claim work.

• Participate, as directed, in research, design, development, and enhancement of insurance or risk-related products.
• Perform other duties as assigned by Claims leadership.

This overview summarizes the role and is not a complete job description.