Description
Serve as the primary point of contact to investigate, evaluate, and resolve insurance claims from first notice through settlement, verifying coverage, gathering documentation, communicating decisions, and processing payments within authority while adhering to company policies and regulations and escalating complex or litigated matters.
- • Receive and set up new claims, verify policy details, and confirm coverage.
- • Examine claim forms, policy declarations, and endorsements to determine coverage.
- • Analyze claim information and document findings, action plans, and recommendations.
- • Review police reports, medical records, bills, and damage reports to assess liability and damages.
- • Coordinate inspections or appraisals and review repair estimates; prepare simple estimates when appropriate.
- • Interview or correspond with claimants, insureds, agents, and witnesses to clarify facts and resolve discrepancies.
- • Obtain statements from claimants, witnesses, providers, and employers as needed.
- • Investigate, evaluate, and settle claims within assigned authority, ensuring fair and timely resolution.
- • Negotiate settlements with claimants, attorneys, or vendors within authority; recommend litigation or escalation when necessary.
- • Set, monitor, and adjust reserves within authority or provide reserve recommendations per policy.
- • Process and issue claim payments, denials, and letters within established guidelines.
- • Review adjuster, vendor, or field reports and authorize next steps or payments within authority.
- • Verify and analyze data to confirm claim validity and compliance with company practices and procedures.
- • Enter claim notes, payments, reserves, and documents in the claim system with clear, concise file documentation.
- • Refer suspicious or complex claims to Special Investigations, field adjusters, or supervisors for further action.
- • Preserve evidence and prepare complete claim files for subrogation or litigation.
- • Coordinate with legal counsel on litigated claims and support discovery as requested.
- • Maintain organized claim files and diaries; track aging, pending items, and follow-ups.
- • Present claim summaries and recommendations in team reviews or committee meetings.
- • Collaborate with field adjusters, appraisers, medical bill review, and vendors to move files to resolution.
- • Review invoices, medical bills, and expenses for accuracy, reasonableness, and fee schedule compliance.
- • Identify and report overpayments, underpayments, and other irregularities; initiate recovery when appropriate.
- • Prepare routine claim reports, status updates, and regulatory notifications as required.
- • Communicate coverage decisions, status, and next steps to customers and agents, delivering high-quality service.
- • Attend mediations or settlement conferences with guidance when appropriate.
- • Comply with all regulatory requirements, privacy rules, and internal best practices.
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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
