Commercial Auto, PIP Claims Examiner II

POSITION SUMMARY: Responsibilities include but are not limited to: DUTIES AND RESPONSIBILITIES: Review PIP coverages and/or identify coverage issues and investigate and analyze the loss event, the injury and other relevant information to make a determination as to coverage and course of action. Negotiate with attorneys to settle PIP Suits and Arbitrations Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information. Concisely and accurately document all actions taken throughout the course of the claim. Investigate prior losses and other information on file and orders reports as needed. Evaluate claims for fraud indicators and potential underwriting issues and process appropriate referrals. Conduct activities in compliance with state and company regulations and guidelines. Render final coverage determination within regulatory guidelines: Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information (Reservation of Right letter, etc.) Need to recognize prolonged or excessive treatment and promptly schedule an IME with the appropriate medical profession via an approved company vendor. Generates and sends appropriate forms to insured/claimant for completion. Processes claims payments. Completes all necessary forms, logs documents into the system, and routes them to the appropriate parties. Need to be an effective team player. Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews and/or IMEs, when required, communicate determinations to appropriate parties within 3 business days. Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits. Establish adequate medical and non-medical benefits reserves for the life of the claim and adjust reserves, if needed. Calculate and issue non-medical benefits (wages, essential services, death benefits). EQUIPMENT OPERATED/USED : Computer, 10-key, printer, copier, fax/scanner machine and other office equipment. SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire. Must have a functional office or workspace with reliable direct ethernet internet connection,