Description
Investigate, evaluate, and resolve insurance claims from first notice through closure. Gather and verify information from policyholders and third parties, determine coverage and liability, document findings, set reserves, and authorize payments or further investigation. Communicate claim status and decisions and maintain accurate, compliant records.
- • Intake and review new claims for completeness and eligibility.
- • Contact insureds, claimants, agents, and witnesses to obtain needed information.
- • Review policy terms, limits, and endorsements to determine coverage.
- • Establish, monitor, and adjust claim reserves per company guidelines.
- • Investigate loss facts through interviews, statements, and document review.
- • Coordinate field adjusters, appraisers, or independent investigators as needed.
- • Evaluate damages, medical bills, wage loss, or repair estimates.
- • Calculate settlement values and recommend or authorize payments within authority.
- • Document all activities and attach supporting records in the claim file.
- • Transmit claims for SIU, legal, or medical review when warranted.
- • Negotiate settlements and obtain releases when appropriate.
- • Issue approvals, denials, or partial denials with clear written explanations.
- • Provide customer service and explain the claims process, coverage, and next steps.
- • Draft and send timely claim correspondence and regulatory notices.
- • Enter and update accurate claim data in claims systems and databases.
- • Request, receive, and track police reports, medical records, and estimates.
- • Process and pay small claims within authority; escalate complex cases.
- • Modify claim details to reflect changes in parties, damages, or coverage information.
- • Maintain diary and follow-up to drive timely resolution.
- • Identify and pursue subrogation, salvage, or recovery opportunities.
- • Recognize potential fraud indicators and refer to SIU as appropriate.
- • Coordinate services with vendors such as rentals, towing, repairs, or restoration.
- • Notify stakeholders of payments, status changes, closures, or additional requirements.
- • Maintain organized electronic files and ensure privacy and regulatory compliance.
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Last reviewed: Jan 2026
