Commercial Auto No Fault, PIP Claims Examiner II at Tristar Insurance

Philadelphia, Pennsylvania, United States -

Full Time

Start Date

Immediate

Expiry Date

31 Jan, 26

Salary

83200.0

Posted On

02 Nov, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Handling, Communication Skills, Customer Service, Data Entry, Analytical Skills, Problem Solving, Time Management, Interpersonal Skills, Negotiation Skills, Fraud Evaluation, Coverage Determination, Medical Treatment Management, Documentation, Regulatory Compliance, Team Collaboration, Computer Proficiency

Industry

Insurance

Description

Job Details Level: Experienced Job Location: Philadelphia Office - Philadelphia, PA Position Type: Temporary Education Level: High School Diploma or GED Salary Range: $72800.00 - $83200.00 Salary Travel Percentage: None Job Shift: Day Job Category: Admin - Clerical Commercial Auto No Fault, PIP Claims Examiner II This a hybrid position working 2 days in office at the client location and 3 days from home. DUTIES AND RESPONSIBILITIES: Experience 2-5 years of handling Pennsylvania, Auto No Fault /PIP claims Ability to multi-task and prioritize the tasks at hand. Ability to perform data entry, email, calendar management, Word and Excel functions. Needs to have excellent verbal and written communication skills. Strong interpersonal and customer service skills Review PIP/ No Fault coverages and/or identify coverage issues and investigate and analyze the loss event, the injury and other relevant information to make a determination as to coverage and course of action. Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information. Concisely and accurately document all actions taken throughout the course of the claim. Investigate prior losses and other information on file and orders reports as needed. Evaluate claims for fraud indicators and potential underwriting issues and process appropriate referrals. Conduct activities in compliance with state and company regulations and guidelines. Render final coverage determination within regulatory guidelines: Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information (Reservation of Right letter, etc.) Need to recognize prolonged or excessive treatment and promptly schedule an IME with the appropriate medical profession via an approved company vendor. Generates and sends appropriate forms to insured/claimant for completion. Processes claims payments. Completes all necessary forms, logs documents into the system, and routes them to the appropriate parties. Need to be an effective team player. Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews and/or IMEs, when required, communicate determinations to appropriate parties within 3 business days. Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits. Establish adequate medical and non-medical benefits reserves for the life of the claim and adjust reserves, if needed. Calculate and issue non-medical benefits (wages, essential services, death benefits). EQUIPMENT OPERATED/USED: Computer, 10-key, printer, copier, fax/scanner machine and other office equipment. SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire Qualifications QUALIFICATIONS REQUIRED: Education/Experience: High school diploma or GED required; Bachelor’s degree in related field (preferred) and a minimum of 2 - 5 years Pennsylvania, Commercial Auto No Fault / PIP casualty related experience; or equivalent combination of advanced education and experience. Knowledge, Skills and Abilities: At least 2 - 5 years Pennsylvania, Commercial Auto No Fault / PIP liability claims experience required. Additional experience handling auto liability claims is a plus. Knowledge of claims handling concepts, practices and techniques, including but not limited to coverage issues and product line knowledge. Demonstrated verbal and written communications skills. Demonstrated advanced analytical, decision making and negotiation skills. Computer proficiency. Ability to communicate effectively and clearly, both orally and in writing. Ability to manage relationships in a fast-paced environment, while demonstrating problem solving and decision-making skills to work with customers. Good analytical abilities to review, exercise judgment and evaluate claims in order to make sound decisions with a minimal amount of supervision. Excellent customer service skills. An understanding of the litigation process and case valuation in multiple jurisdictions. Ability to carry out detailed written or verbal instructions, ability to respond to requests effectively and efficiently and exhibit good common sense. An ability to handle assigned claims following company guidelines and industry best practices with a minimal amount of supervision. Time management skills, organizational skills and ability to prioritize issues and tasks. Ability to effectively operate computer equipment and applications. Independence, flexibility and creativity. Here are some of the benefits you can enjoy in this role: Medical, Dental, Vision, Disability & Life Insurance 401(k) plan Paid time off. Paid holidays. Mental and Physical Requirements: MENTAL AND PHYSICAL REQUIREMENTS 1. MENTAL EFFORT a. Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. Solve practical problems; variety of variables with limited standardization; interpret instructions. X Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts. b. Mathematical development: Simple additional and subtraction; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. X Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination. Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application. c. Language development: Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing. Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction. Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants. Ability to compose original correspondence, follow technical manuals, and have increased contact with people. X Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data. 2. PHYSICAL EFFORT a. Physical activity required to perform the job: X Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds frequently c. Exerting a negligible amount of force constantly to move objects (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work). Medium work: a. Exerting up to 50 pounds of force occasionally b. Exerting up to 20 pounds of force frequently c. Exerting up to 10 pounds of force constantly to move objects Heavy work: a. Exerting up to 100 pounds of force occasionally b. Exerting up to 50 pounds of force frequently c. Exerting up to 20 pounds of force constantly to move objects Very heavy work: a. Exerting in excess of 100 pounds of force occasionally b. Exerting in excess of 50 pounds of force constantly to move objects c. Exerting in excess of 20 pounds of force constantly to move objects Visual requirements necessary to perform the job: Far vision: clarity of vision at 20 feet or more X Near vision: clarity of vision at 20 inches or less X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are Color vision: ability to identify and distinguish colors Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point 2. PHYSICAL EFFORT (cont.) FREQUENCY c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally): Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion. Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium. Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles. Kneeling: Bending legs at knee to come to a rest on knee or knees. Crouching: Bending the body downward and forward by bending legs and spine. Crawling: Moving about on hands and knees or hands and feet. Reaching: Extending hand(s) and arm(s) in any direction. Standing: Particularly for sustained periods of time. Walking: Moving about on foot to accomplish tasks, particularly for long distances. Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward. Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion. Foot Motion: Using feet to push pedals. Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles. X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling. X Grasping: Applying pressure to an object with the fingers and palm. Frequently Occasionally 2. PHYSICAL EFFORT (cont.) FREQUENCY X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts. Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips. X Repetitive Substantial movements (motions) of the wrists, hands, Motion: and/or fingers. Frequently Frequently Frequently 3. WORKING CONDITIONS Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure. WORKING CONDITION ENVIRONMENTAL FACTOR NATURE/REASON OF EXPOSURE FREQUENCY Dirt/Dust Noise Temperature extremes Dampness Vibrations Equipment movement hazard Chemicals/solvents Electrical shock Significant work pace/pressure Odors/Fumes Other (specify):

Responsibilities

The role involves reviewing and analyzing Pennsylvania Auto No Fault/PIP claims to determine coverage and course of action. The examiner will maintain communication with involved parties and document all actions taken throughout the claims process.