||April 25, 2022
Mitsui Sumitomo Marine Management U.S.A., Inc. is one of the world’s top ten property/casualty insurance carriers with over 40,000 employees worldwide.
This position is responsible to adjust assigned claims within delegated limits of authority, conduct timely and thorough investigations, handle subrogation claims, and complete fair and equitable claim settlements in accordance with MSMM Claim Handling Guidelines to ensure services are provided in a fair, equitable and timely manner.
Essential Duties and Responsibilities include the following. Other duties may be assigned. (Identify what percentage of time will be spent on the essential functions)
Claims Handling 60%
- Receives new claim assignments, analyzes the nature of the claim/loss to determine required investigation and handling. Determines and identifies coverage issues or questions of claim compensability.
- Is responsible for direct handling Medical-only, Complex Medical-only and Indemnity claims in full compliance with Special Claim Handling Requirements & MSMM Claim Handling Guidelines. Claim handling responsibilities also involve frequent and professional claim handling interaction with the Customer, Injured Workers, and Medical Personnel in an on-site claim handling setting.
- Conducts an investigation to collect all necessary information for assigned claims and appropriately evaluates completed investigation and case facts to determine merits of each claim. Completes job process investigations on the production line with Customer Safety Personnel and participates in Complex Case Meetings in full compliance with Special Claim Handling requirements by plant affiliate location.
- Initiates reserve changes within assigned authority, makes recommendations to supervisor manager where assigned authority is exceeded.
- Timely/ appropriately reports WC cases to the Claims Manager that will require Reserve Consultation Review at required thresholds with the Customer (arising reserves and reserve increases), to ensure compliance with Special Claim Handling requirements by plant affiliate location.
- Is fully complaint in completing WC Claim Summaries on assigned cases as required.
- Manages, controls and negotiates timely and equitable claims payments and settlements in accordance with jurisdictional and fair claims practices requirements and Company policy and Special Claim Handling requirements.
- Maintains diary and ensures appropriate claims system documentation as required by company claim manuals and procedures. May be responsible for submission of claim forms and reports required by outside agencies.
- Responsible for attendance at required MTMUS location meetings as assigned, depositions and WC pre-hearings as required.
- Investigates and evaluates recovery potential. Performs all necessary recovery activities.
- Communicates to claims staff information regarding Workers’ Compensation statutes and revisions.
- Reports to Claims Manager regarding all new and continuing developments on claims being reportable to MSMM Home Office under published guidelines.
- Ensures compliance with all adjuster licensing regulations and requirements.
Customer Service 30%
- Services the claim needs of our customers including insureds, claimants, brokers, etc., in accordance with company policy and procedures, and attends client visitations with underwriters and other parties to conduct presentations and reviews.
- Maintains ongoing communication with all customers throughout the claims process in an effort to provide timely and appropriate claim status as appropriate and/or required by statutory regulations.
Regulatory and Operational Compliance 10%
- Completes timely and accurate data reports to state reporting agencies to ensured full compliance with MSMM and regulatory requirement.
- Maintains full compliance with all regulatory Fair Claim Practices Acts and state and federal regulations.
- Maintains full compliance with all state licensing and continuing education requirements to ensure current and appropriate filing/standing of all adjuster licenses.
Education and/or Experience
- High School Degree or G.E.D. is required. Bachelor’s degree (B. A.) is preferred.
- 3+ years of claims experience, including ability to successfully negotiate settlements, verify coverage, appropriately set reserves, successfully complete investigations and understand rules associated with state regulations
- Multi-state adjuster licenses required. TX claims handling required.