Claims Examiner - Claims Specialist

Falls Lake Insurance is the specialty admitted segment of James River Group Holdings, Ltd. James River Group received national recognition as a Top Workplaces USA winner in 2021, 2022, and 2023.

We are committed to providing a stable and rewarding work envirotnment supported by our Core Values and Guiding Principals: Integrity, Accountability, Innovation, Customer Service, Communication, and Teamwork.

James River Group Holdings, Ltd. is a Bermuda-based insurance holding company which owns and operates a group of specialty insurance and reinsurance companies. The Company operates in two specialty property and casualty insurance segments: Excess and Surplus Lines and Specialty Admitted Insurance. The Company ends to focus on accounts associated with small or medium-sized businesses in each of its segments. Each of the Company’s regulated insurance subsidiaries are rated “A-“ (Excellent) by A.M. Best Company.

Job Summary
The Claims Examiner, under direct supervision of the Claims Assistant Manager or Claims Manager, will handle lost time claims with a close period of indemnity benefits and non-complex medical injuries. Works on problems of limited to moderate scope where analysis of situations or data requires a review of a variety of factors. Exercises judgment within defined procedures and practices to determine appropriate action. Duties include: Review of claims to determine compensability, review of medical documentation, establishment of reserves, maintain diary within Best Practice Standards. The Claims Examiner will communicate with insureds, claimants and medical providers. The Claims Examiner will ensure that state claims handling requirements are met as well as compliance with our Claims Best Practices. The Claims Examiner is expected to learn and become proficient in the handling of commercial auto claims with limited to moderate period of disability.
Duties and Responsibilities

• Continuously exhibit and uphold Core Values of Integrity, Accountability, Communication and Teamwork, Innovation and Customer Service.
• Conduct three point contacts
• Determine compensability
• Issue workers’ compensation benefits
• Develop plans of action to resolution, coordinate return to work efforts and approved medical payments.
• Investigates Subrogation and negotiate limited settlements within authority level.
• Maintains contact with policyholders and injured workers.
• Ensure claims files are appropriately documented.
• Completes and files appropriate FROI and SROI’s as required by individual State Workers’ Compensation Statute and EDI reporting regulations.
• Manages claims in accordance with Falls Lake Best Practices
• Employs appropriate claims management techniques and direct intervention (referrals for nurse case management, independent medical examinations, utilization review) to manage each claim.
• Makes decisions within delegated authority.
• Have a general understanding of all legislative requirements and is able to take direction to meet those requirements in a prudent business manner.
• Maintains a license for all states and products serviced as required.
• Organize and update all reference material to reflect current legislation and regulatory compliance.
• Comply with all quality control standards set by the company for the handling of claims. Comply with all procedures set forth by the company for performing the job as it relates to the various components of claim administrative services.
• Immediately notify Management of any unusual lawyer inquiries, insurance carrier inquiries, or department of insurance inquiries.

Knowledge, Skills and Abilities

• Familiar with the claims handling process
• Knowledge of medical terminology
• Customer Service focused
• Organizational skills
• Time Management skills
• Excellent oral and written communication skills
• Attention to detail
• Strong Computer Skills
• Hands on Learner
• Ability to multi-task
• Team Attitude
• Ability to successfully obtain the required state adjusters’ licenses within six (6) months following the completion of Company-provided licensure training courses and maintain appropriate licensure thereafter.

Experience and Education

• Four-year college degree preferred
• One to three years of claims handling experience
• Experience in working with liability and coverage issues
• Experience negotiating settlements with claimants and attorneys
• Multi-jurisdictional claims experience preferred, may be required depending on type of claim
• Adjuster license and/or certifications preferred

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