Claim Specialist - Michigan PIP

Job Type

Full time

Salary

Hybrid

Monday-Friday 8am-5pm ET

As a Claim Specialist, you will evaluate coverage, assess claim exposures, and make informed decisions that drive fair and timely resolutions. Working closely with members, medical providers, attorneys, and internal partners under minimal supervision, you'll manage challenging and complex claim scenarios while ensuring compliance with applicable regulations and company standards. The ideal candidate will have experience interpreting and applying Michigan No-Fault reform regulations to support accurate claim handling and benefit determinations.

This role is ideal for a detail-oriented professional who thrives on problem-solving, sound judgment, and delivering positive outcomes for members.

• Review assigned claims and initiate claim handling activities.
• Contact insureds and other affected parties to gather information and set expectations for the claims process.
• Document claim activity and maintain accurate records within the claims management system.
• Perform complex coverage analysis and identify all applicable policyholder benefits.
• Establish and manage sub-claims as needed.
• Conduct thorough investigations to determine coverage applicability, claim validity, policy limits, exclusions, and recovery opportunities.
• Analyze claim facts, damages, state laws, and other relevant factors impacting claim decisions.
• Evaluate the financial value of losses and authorize appropriate claim payments.
• Negotiate settlements and claim resolutions using strong negotiation skills.
• Refer claims to specialized departments when necessary, including Underwriting, Recovery Units, and the Claims Special Investigation Unit (SIU).
• Ensure complete and accurate claim documentation, coding, closure activities, and compliance with company procedures.
• Handle intermediate to complex Michigan Personal Injury Protection (PIP) claims, including:
• Fractures
• Mild closed head injuries
• Surgical procedures
• Attendant care claims
• Manage claims involving the Michigan Catastrophic Claims Association (MCCA).
• Handle attorney-represented claims and effectively navigate legal involvement throughout the claim process.
• Investigate and manage losses that may extend beyond standard PIP claim scenarios.
Collaborate with insureds, physician offices, medical providers, and insurance carriers to obtain necessary documentation and information.
• Review medical and claim-related information to make accurate coverage and payment determinations.
• Maintain compliance with applicable state regulations, company policies, and claim handling standards.

Required

• Complete ACG Claim Representative Training Program or demonstrate equivalent knowledge or experience
• In states where an Adjuster’s license is required, the candidate must be eligible to acquire a State Adjuster’s license within 90 days of hire and maintain as specified for appropriate states
• A valid driver's license is required if the primary responsibilities of the role involve conducting in-person inspections or frequent in-person meetings with members

• Three years of experience or equivalent training in the following:
• Negotiation of claim settlements
• Securing and evaluating evidence
• Preparing manual and electronic estimates
• Subrogation claims
• Resolving coverage questions
• Taking statements
• Establishing clear evaluation and resolution plans for claims

• Advanced knowledge of:
• Essential Insurance Act (Michigan)
• Fair Trade Practices Act as it relates to claims
• Subrogation procedures and processes
• Intercompany arbitration
• Handling simple litigation
• Negligence Law
• No-Fault Law
• medical terminology and human anatomy
• MCCA and attorney…