Description
Evaluate, process, and resolve insurance claims by verifying coverage, analyzing documentation, and determining liability and payment amounts. Gather and validate information from policyholders and third parties, coordinate investigations and vendors, ensure regulatory and policy compliance, and maintain accurate, auditable claim records.
- • Intake, triage, and set up new claims in the system.
- • Review policies and endorsements to confirm coverage and exclusions.
- • Evaluate liability, damages, and causation based on documentation and statements.
- • Calculate recommended payments and set or adjust reserves.
- • Prepare and review claim documentation for completeness and accuracy.
- • Contact policyholders, providers, and witnesses to obtain missing information.
- • Interview claimants and record detailed statements.
- • Request and analyze police reports, medical records, estimates, and appraisals.
- • Identify indicators of fraud and refer cases to SIU when appropriate.
- • Authorize payments within authority or route claims for further approval or investigation.
- • Negotiate settlements within authority and document rationale.
- • Coordinate independent adjusters, appraisers, and other vendors.
- • Maintain accurate notes, financial transactions, and correspondence in claim files.
- • Communicate claim status, decisions, and next steps to insureds and agents.
- • Prepare clear decision letters, summaries, and adverse action notices.
- • Update claim files to reflect new information, coverage determinations, and payments.
- • Ensure claims comply with policy terms, regulatory requirements, and company guidelines.
- • Prepare required regulatory forms and reports.
- • Pursue subrogation, salvage, or recovery opportunities when applicable.
- • Support litigation management by providing documentation and testimony preparation as needed.
- • Generate reports and metrics on claim inventory, cycle time, and outcomes.
- • Guide customers on the claim process and provide referrals when appropriate.
- • Close claims when obligations are met and notify stakeholders of outcomes.
- • Organize and maintain complete, auditable claim files.
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Last reviewed: Jan 2026
