Description
Review and evaluate claim files for coverage, liability, and damages; ensure settlements and payments comply with policies, laws, and company procedures. Authorize payments and reserves within authority, provide oversight and quality review for adjusters, and coordinate litigation or complex settlements as needed.
- • Review claim forms, policy language, and supporting records to confirm coverage.
- • Analyze investigation findings and provide coverage, liability, and settlement recommendations.
- • Evaluate police reports, medical records, bills, and damage estimates to assess liability and damages.
- • Review and validate property damage estimates prepared by adjusters or vendors.
- • Communicate with agents and claimants to clarify documentation and address discrepancies.
- • Obtain statements or written confirmations from relevant parties to support claim decisions.
- • Evaluate and settle assigned claims within authority, ensuring fair, timely, and compliant outcomes.
- • Establish and adjust reserves in line with exposure and company guidelines.
- • Handle complex or high-exposure files and ensure high service standards.
- • Authorize and process payments within authority.
- • Audit adjuster files, escalate questionable claims to the special investigations unit, and determine payment authorization.
- • Verify and analyze data to validate claims and ensure settlements follow policies and procedures.
- • Update claim systems with payments, reserves, and detailed file notes.
- • Refer files to field adjusters, appraisers, or the special investigations unit when additional investigation is required.
- • Compile and preserve documentation to support litigation or subrogation.
- • Coordinate with defense counsel on litigated or potentially litigated claims.
- • Request additional information from claimants, providers, or employers to complete file development.
- • Maintain organized, compliant claim files and track cases requiring detailed analysis.
- • Present coverage and settlement recommendations at claim committee meetings.
- • Provide guidance and quality review feedback to adjusters to ensure proper methods are followed.
- • Review medical and legal bills to control expenses and ensure fee guideline compliance.
- • Identify subrogation and recovery opportunities and pursue reimbursement when appropriate.
- • Report overpayments, underpayments, and other irregularities.
- • Report and coordinate with reinsurance on qualifying losses.
- • Prepare management reports on claim status, reserves, and outcomes.
- • Ensure regulatory and statutory reporting requirements are met.
- • Attend mediations, depositions, or trials as needed.
- • Verify wage and employment information for lost wage or workers' compensation claims.
- • Negotiate settlements within authority or recommend litigation or mediation when appropriate.
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O*NET occupational data (work activities, skills, knowledge).
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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
