What are the responsibilities and job description for the Claim Representative position at AMERIND?
AMERIND is a federally chartered, tribally owned corporation, formed under Section 17 of the Indian Reorganization Act (25 U.S.C. § 5124) by its Members, the governmental units of federally recognized Tribal Nations that administer federally funded housing programs for American Indian and Alaska Native families. AMERIND has the operating authority to work with Tribal Governments, Enterprises, and Citizens for Property and Liability, Workers Compensation, Homeowners and Renters, Employee Benefits coverage, Fleet Auto coverage, and Critical Infrastructure development.
Position Characteristics and Competencies
- Excellent time and project management skills
- Meticulous attention to detail
- Proficiency with industry-related software applications
- Excellent customer relations skills
- Ability to provide transparent information and demonstrate high customer service
- Problem-solving and analytical thinking
- Strong verbal and written communication skills
- Ability to handle multiple tasks simultaneously
- Interest in discovering and developing new ideas
- Agile and adaptable decision-making
- Team collaboration
- Good fundamental understanding of insurance policy terminology
Job Summary
Possesses extensive knowledge of liability, workers' compensation, medical-only claims, and/or property claims. Demonstrates excellent judgment, deep policy knowledge, and expertise in dealing with significant losses. Assigns liability and brings about a fair and just resolution, determines eligibility for workers’ compensation, determines coverage for medical expenses, and determines the extent of coverage for property loss; arrives at a reasonable settlement for the policyholder.
This job description does not represent an inclusive list of all duties encompassed in this position.
Job Responsibilities
- Primary: Liability
- Determination of Liability:
- Establishing liability reserves and attorney expenses
- Evaluating policy coverage (liability allegations and defense coverage).
- Evaluating essential documents related to the incident (surveillance footage, and photo)
- Obtaining key documentation from the claimant and policyholder.
- Inputting all risk information into the claim system
- Negotiating and securing a release of all claims from the claimant party.
- Preparing the claim file for closure
- Completes field claims assignments as assigned by the company.
- Presents claims material on behalf of the company.
- Participates in Teams virtual calls as assigned by the Department.
- Handles a high volume of liability and workers' compensation claims.
- Participates in mediation hearings.
- Communicates with policyholders, attorneys, and associates over the telephone, in person, and in written correspondence.
- Determines liability exposure, completes coverage analysis and gives a liability determination.
- Submits a field report with a narrative, photos, and any other pertinent information regarding the investigation process.
- Knowledge of liability, homeowner and commercial policy forms.
- Knowledge of evaluating third-party field information and making a determination of liability to secure a resolution for the claim file.
Secondary: Workers’ Compensation
- Determination of Compensability:
- Investigates the claim facts, determines if compensability is accepted under the work comp policy.
- Ensures that adequate reserves are set following department guidelines to cover potential future medical treatments and bill fees for the claim file.
- Maintains regular communication with the injured worker's employer and medical facility, either through email or phone, to ensure that all necessary information is collected and recorded in the claims system.
- Pays all medical bills and fees if the claim is accepted. If the claim is denied, a notice of denial and claim petition will be sent to the injured worker.
- If a claim petition is received, the claim will go to a hearing examiner for a final determination.
- Reviews the claim file to confirm that all supporting documents are recorded in the claims system.
- Issues a denial letter and includes all relevant documents in the claim file. The adjuster then closes any remaining reserves and prepares the file for closure.
- Properly investigates and handles workers’ compensation files for medical-only claims.
- Interview claimants, specialists, witnesses, physicians, or other professionals as necessary.
- Determines compensability and total value of claim.
- Establishes timely and appropriate case reserves.
- Negotiates directly with the claimants as necessary.
- Uses automated diary system to provide claim management.
- Reviews and follows up on claims as needed and closes files as appropriate.
- Documents all action plans and evaluations for claim resolution.
- Reviews incoming provider and vendor bills for appropriateness.
- Approves or denies bills to process through bill review for payment out of claim file.
- Maintains organized electronic files.
- Addresses customer complaints and inquiries in an exemplary and professional manner.
- Achieves specific performance outcomes related to quality and quantity of work as established by management.
- Provides cost containment for individual claims and overall claim costs for an account to achieve account profitability.
- Conducts in-person claim reviews when scheduled or requested.
Third: Property
- Determines Coverage Evaluation and Resolution, which includes the following:
- Establishing and adjusting reserves for the claim file
- Customer communication, by phone or in writing
- Evaluating policy coverage for the risk
- Evaluating field reports of the damage risk
- Obtaining additional risk information
- Inputting all risk information into the claim system
- Securing a resolution payment for the policyholder
- Preparing the claim file for closure
- Investigates claims on-site, evaluating damages, completing coverage analysis, damage assessments, and cause/origin determination, and submits a field report with a narrative, estimate, photos, and any other pertinent information for the damages.
- Determines property damage evaluation using Xactimate software, negotiates settlements, and approves supplement expenses. Prepares declination letters when coverage is not applicable under the policy.
- Prepares correspondence to policyholders with updates on their claims, including settlement explanations and closure letter summaries. Obtains any supporting documents for the claim file.
- Within department guidelines and metrics, responsible for managing daily work assignments and correctly closing claim files. Performs subrogation and recovery of property claims where there is another responsible party.
- Maintains claim files and other related documents per best practices.
- Maintains professional and technical knowledge by obtaining certificates and designations: AIC, Property Technical Certificate (PTC 1-2-3), Water Damage
- Restoration Tech Certificate, Property Examiner, Residential Estimating, California Earthquake of Flood Adjusting courses from accredited institutions.
- Participates in cross-functional team process improvement projects.
- Performs other duties as assigned.
Supervision of Others
N/A
Minimum Qualifications
- An Associate Degree in Insurance, Economics, Business Administration, or a related field is required, as well as two to four years of liability, workers' compensation, and/or property experience required.
- A bachelor's degree in insurance, economics, business administration, or a related field is preferred.
- Designations and certificates from accredited insurance institutions are preferred.
- Minimum of two years of desk adjusting experience involving all business lines (liability, workers' compensation, and property claims).
- A minimum of two to four years of experience in handling liability cases, including litigation and working with attorneys, is required.
- A minimum of two years experience handling medical-only workers' compensation claims required.
- A minimum of three years of field adjusting experience using software applications such as Symbility, Xactimate, or Xactanalysis is required.
- A minimum of three years of carrier risk information system, such as Guidewire or Sapiens, is preferred.
- Must possess a valid driver’s license
- Must be able to pass a background investigation successfully. No felony, theft, or fraud convictions.
- Must be able to travel 30% by car or airplane and for short and extended periods of time. as needed.
Additional Eligibility Requirements
- New employees must complete the Associate in Insurance (AINS) designation within six months from the end of the 90-day evaluation period to be eligible for advancement and incentive compensation.
- For continued employment, employees must complete an elective course and six hours of professional development within 12 months after the end of the 90-day evaluation period.
Knowledge/Skills/Abilities
- Knowledge of homeowner and commercial policy forms.
- Knowledge of evaluating third-party field information and finalizing coverage evaluation and resolution for the claim file.
- Knowledge of applicable federal, state, tribal, and local laws, regulations, and requirements.
- Knowledge of property, auto, and liability insurance laws, policies, and regulations.
- Knowledge of the use of field equipment such as a measuring tape, ladder, and camera.
- Ability to operate drone equipment.
- Knowledge of occupational safety theory, procedures, and equipment.
- Ability to successfully obtain certificate(s) in Property Technical Certificate (PTC 1-2-3) upon employment.
- Ability to interpret insurance policies, claim procedures, and federal and state regulations.
- Ability to communicate effectively in the English language, both verbally and in writing.
- Ability to analyze situations and adopt appropriate courses of action.
- Ability to communicate verbally and in writing with policyholders, third-party adjusters, experts, public adjusters, and brokers.
- Ability to work with minimal supervision.
- Ability to work effectively under stressful conditions.
- Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds, employees and officials.
- Ability to develop and interpret policies, procedures, and regulations.
- Ability to maintain an accurate and organized filing system of complex insurance records and reports.
- Ability to handle multiple tasks and meet deadlines.
- Ability to exercise independent judgment.
- Ability to train and present information to others.
- Ability to follow oral and written instruction.
- Ability to collect and analyze data, prepare and present accurate reports and recommendations.
- Ability to act with integrity and maintain confidentiality.
- Skill in performing statistical and mathematical computations.
- Skill in preparing, presenting, reviewing, and analyzing insurance claims, forms, and reports.
- Skill in providing excellent customer service.
- Skill in operating business computers and office machines, including in a Windows environment, specifically Word, Excel, Access, and presentation software (such as PowerPoint).
- Required to complete fieldwork claim assignments as assigned by the company.
- Required to be able to travel for short and long periods as needed.
- Required to present claims material on behalf of the company.
- Required to participate in Team Virtual calls as assigned by the Department.
- Required to mentor team members within the department.
- Must be able to handle high volume and complex property claims.
- Must be able to operate a Drone to complete fieldwork
- Database management skills.
- Excellent telephone communication skills.
- Working Conditions & Physical Demands
- Typical business office setting with moderate noise level and outdoor settings with a high noise level.
- A non-office environment may be encountered for offsite presentations and support of company activities.
- While performing field work assignments duties, one may be exposed to natural weather conditions and temperatures, various dusts, smoke and mists, and normal debris and hazards.
- Must be able to work at a computer and phone for more than 6 hours daily.
- Must be able to speak clearly.
- Must be able to use hand for dexterity of motion.
- Frequently required to stand, walk, and reach with hands and arms.
- Must have the ability to lift 50 lbs occasionally.
- Must have ability to climb ladders for property inspections.
- Must be willing to travel as necessary; COVID-19 vaccination preferred.
Physical Exam
Employee is required to successfully pass an annual physical exam to certify that the incumbent is capable of performing the physical demands of the job.
Hiring of AMERIND employees is subject to Section 7(b) of the Indian Self-Determination Act (25 U.S.C. §5307(b)), which requires that, to the greatest extent feasible, preference and opportunities for training and employment shall be given to Native Americans and Alaska Natives.
