PIP Adjuster II

We’re looking for the best talent to help The General® to bring quality insurance to people who need it the most. Compensation may vary based on the job level and your geographic work location Compensation Minimum:$51,200.00 Compensation Maximum:$76,800.00 Job Description and Responsibilities: Essential Functions Handles complex claims in complex PIP/no-fault venues. Uses discretion and independent decision making in claims handling to develop action plans and determine appropriate claim adjustments. Ensures compliance with state and company procedures and timeframes and maintains adequate and accurate reserves. Elevates payments, reserves and coverage determinations outside authority to management. Examines PIP and medical payments claims to determine eligibility of coverage and benefits through fact gathering and claim investigations. Investigations may include: reviewing police reports, taking recorded statements, analyzing and interpreting policies, state regulations and statutes and referring files to the special investigations unit. Provides exceptional customer service by assisting customers throughout the 1st party medical claims process. This includes but is not limited to: explaining the applicable benefits, eligibility, required forms and procedures, providing claim status updates and information through both verbal and written communications and issuing timely and accurate reimbursement of medical, wage loss, and other benefits available under the policy as appropriate. Responsible for obtaining, analyzing, adjusting and processing timely and accurate payments on medical bills within prescribed authority. Bill analysis will include: reviewing medical records and codes for reasonableness, relatedness and duplicate charges, reviewing compliance with applicable fee schedules, ensuring accuracy in application of applicable co-pays and deductibles, coordinating and reviewing results of independent medical examinations and peer reviews and making claim handling recommendations as appropriate. Responsible for determination and issuance of timely and appropriate reimbursement for lost wages by analyzing disability medical records, employment/wage information and other pertinent documentation. Additionally, reviews claims made for other reimbursable expenses and determines proper payment. Responds promptly to written and verbal inquiries from injured parties, medical providers, and attorneys, including by not limited to: PIP payment logs, claim information, policy information and payment information. Responsible for properly and timely reserving the claim file, Issues payments to medical providers, customers and vendors in accordance with specified state and company timeframes and within authority. Requests authority from management as appropriate. Other duties as assigned Education and Experience High school diploma/GED required Bachelor’s Degree preferred 3 years of PIP/no-fault claims adjusting experience and solid understanding of personal injury protection laws, regulations and statues required Active Adjuster’s License preferred   Knowledge, Skills and Abilities (KSAs) Intermediate knowledge of CPT codes, billing practices & procedures and the ability to utilize medical reference tools to research information as needed Excellent customer service skills including both verbal and written communication Ability to multi-task, manage time effectively and has strong organizational skills Detail oriented and ability to draw independent conclusions Must know how to type and be proficient with Microsoft Office software Ability to perform basic math calculations (addition, subtraction, multiplication, and division) as well as the calculation of averages and percentages Bi-lingual a plus % Of Time Spent Traveling 0 – 25% When you work at The General you can expect benefits that support your physical, emotional, and financial wellbeing. You will have access to comprehensive medical, dental, vision and wellbeing benefits that enable you to take care of your health. We also offer a competitive 401(k) contribution, a pension plan, an annual incentive, and a paid-time off program. In addition, our student loan repayment program and paid-family leave are available to support our employees and their families. Interns and contingent workers are not eligible for American Family Enterprise benefits. Stay connected: Join Our Enterprise Talent Community!