Claims Adjuster I - Tahlequah, United States - Cherokee Nation

Description

Job Summary:

Claims Adjuster I plans, carries out, and/or coordinates most the work required to process an insurance claim. Confirms alleged circumstances/property damage/employee injury. Reviews policy for determination of coverage. Investigates and compiles claims documentation/evidentiary support. Coordinates respective services with providers/TPA. Obtains authorization for settlements/action plans. Prepares analysis/reports on findings, activities, claims history, etc. Maintains records.

Reviews policy to determine application of coverage and eligibility. Conducts interviews with all parties/witnesses. Interprets insuring contracts, endorsements, and exclusions. Develops action plans, coordinates service providers and obtains authorization by management for implementation for said plans. Coordinates/conducts interviews with insured, claimants, witnesses, medical providers, attorneys, etc. to identify and compile important documents/evidentiary support. Maintains records and files accordingly to be used in legal/court proceedings. Appears and testifies in court proceedings, give verbal depositions, attends meetings as warranted, and works closely with attorneys. Prepares reports on investigative findings, court proceeds, Arbitration, Appeals, claims activity, frequency/severity, large claims and coverage/service issues on a routine/regular basis. Prepares audit schedule includes of all insured entities. Generates accurate reports and statistical data for all insureds covered under the Cherokee Nation Workers' Compensation Act and/or insurance policies, recommends legislative action to mitigate coverage issues. Serves on various committees, TWCA, etc. Monitors claims activities to ensure quality of claims service providers and frequently communicates with all parties involved with he claim. Bills, reconciles, and reports on billing of program deductibles within self-insured layer. Tracks payments from TPA/Reinsurer to ensure 100% recovery of large claims. Schedules deposits/offsets to Loss Fund and Fringe. Maintains all confidential filing system. Performs all billing, accrual, and reserving tasks/reporting. Determines maximum out of pocket expenses by applying Loss Development Factors (LDF) and trending for inflation. Generates reserving and ALA Performance report to management. Records are audited annually by external CPA firms and funding agencies. Generates and maintains Stop Loss graphs/tables and reports. Compiles and produces and maintains Ultimate Value of Losses to be utilized when management entertains Commutation Agreement on open loss year. Writes and participates in groups that author or recommend amending tribal law/legislation/policy. Attendance must comply and be maintained in compliance with unit operating policies. Other duties/projects as assigned.

SUPERVISORY RESPONSIBILITIES

No supervisory responsibility.

EDUCATIONAL REQUIREMENT

Bachelor's degree from 4-year college or university; or six years related experience; or equivalent combination of education and experience.

EXPERIENCE REQUIREMENT

At least three (3) years' experience in a related field.

COMPUTER SKILLS

An individual should have knowledge of Accounting software; Contact Management systems; Database software; Design software; Human Resource systems; Internet software; Inventory software; Payroll systems; Spreadsheet software and Word Processing software.

CERTIFICATES, LICENSES, REGISTRATIONS

Must possess a valid driver's license with a driving history verified through a motor vehicle report that meets requirements for Cherokee Nation underwriting rating. Must obtain Adjuster license within 60 days of employment and maintain Adjusters' License throughout employment.

OTHER SKILLS AND ABILITIES

Knowledge of principles and practices of claims administration. Knowledge of contract law liability and legal liability. Effective oral and written communication skills. Excellent interpersonal skills. Ability to organize and prioritize work. Ability to multi task.

OTHER QUALIFICATIONS

Employee must not and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIGs Cumulative Sanction Report, or the GSAs List of Excluded Providers, or listed on the OIGs List of Excluded Individuals/Entities (LEIE).

Experience with PowerPoint presentation is preferred.

PHYSICAL DEMANDS

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is frequently required to use hands to finger, handle, or feel; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee is occasionally required to stand; walk; climb or balance and taste or smell. The employee must regularly lift and /or move up to 10 pounds, frequently lift and/or move up to 25 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

WORK ENVIRONMENT

While performing the duties of this Job, the employee is occasionally exposed to outside weather conditions; extreme cold; extreme heat and risk of electrical shock. The noise level in the work environment is usually moderate.