Description
Analyze and validate insurance claims to ensure coverage, liability, and payments comply with policy language, regulations, and company procedures. Review open and settled files, recommend reserves and settlements, process payments within authority, and escalate complex matters. Collaborate with adjusters, legal, SIU, and reinsurance to support investigations, litigation, and fair, timely resolution.
- • Maintain organized digital claim files and track items requiring follow-up or detailed analysis.
- • Present analyses and recommendations at claim or roundtable meetings.
- • Perform quality reviews and provide feedback to adjusters on adherence to guidelines.
- • Audit medical and legal invoices; enforce litigation management and expense controls.
- • Verify insurable interest and ownership documentation when applicable.
- • Identify and report overpayments, underpayments, and compliance irregularities.
- • Coordinate with reinsurance partners to report losses and recover reimbursements.
- • Prepare claim metrics and data quality reports for management and data teams.
- • Collect financial documentation when needed for fraud review or business interruption claims.
- • Determine coverage by reviewing claim forms, policy language, and endorsements.
- • Analyze investigation findings and document recommendations for liability, damages, and next steps.
- • Review police reports, medical records, bills, and repair estimates to assess liability and damages.
- • Evaluate adjuster and vendor property damage estimates for accuracy and consistency.
- • Contact agents and claimants to resolve data gaps, discrepancies, or red flags.
- • Obtain statements or documentation from witnesses, providers, or employers to support settlement or denial decisions.
- • Evaluate and settle claims within authority, ensuring fair, timely, and compliant outcomes.
- • Set and adjust loss and expense reserves; provide rationale consistent with company policy.
- • Support handling of complex or high-exposure files with proactive, service-focused file management.
- • Process and authorize payments within delegated authority.
- • Audit adjuster findings and perform additional analysis on questionable claims before authorizing payments.
- • Validate data and calculations to confirm claim legitimacy and adherence to procedures.
- • Enter and update claims, reserves, and payments in the system with clear, concise file notes.
- • Refer suspected fraud or complex issues to SIU, legal, or senior adjusters.
- • Compile evidence files and summaries to support litigation or arbitration.
- • Coordinate with defense counsel on litigation strategy, discovery, and evaluation.
- • Request medical bills, treatment notes, or wage statements to substantiate claimed losses.
- • Prepare settlement evaluations and support mediations or trials as needed.
- • Verify employment or wage history relevant to wage-loss or liability claims.
- • Negotiate settlements within authority or recommend litigation/denial when appropriate.
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This site includes information from O*NET by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA), used under the CC BY 4.0 license. Career Clutch has modified some of this information for student readability. USDOL/ETA has not approved, endorsed, or tested these modifications. O*NET® is a trademark of USDOL/ETA.
Last reviewed: Jan 2026
