Claims Operations Specialist

Pennsylvania Lumbermens Mutual Insurance Company

Position: Claim Operations Specialist  Department: Claims 

Reports To: VP Claims 

Position Summary: The purpose of this position is to manage the operational support functions of the claims department. The position has broad authority over claim systems, processes and workflows.  

Essential Functions and Responsibilities:

Manage Subrogation/Assist Subrogation Coordinator – 

• Send referrals to spartan along with pertinent documentation.
• Send demands out to adverse carrier with pertinent documentation. 
• Follow up with adverse carriers for payments and negotiation. 
• Handle all emails from Spartan as well as other carriers, regarding settlement from adverse carrier, gathering of more liability supports from various contacts, insured, driver, etc.
• Applying payments as they come in and  instructing handlers to issue deductibles as well as closing of file.
• Handling of calls from brokers and  insureds for various status’s of subro claims.

Reports –

• Utilizing PowerBI to extract and analyze claim data to create management reports for senior staff distribution.
• Produce other claim reports for Senior Management as requested.
• Produce claim reports for Regulatory and Compliance for state requirements and update states websites accordingly if applicable.
• Produce CAT reports for reinsurers.

Reinsurance – 

· Sending initial report of reinsurance claim file to reinsurers via Claims Plus.

· Handling all email follow up/requests from reinsurers. 

· Updating financials and sending proofs as needed for reinsurance claims. 

· Reporting CAT proofs to reinsurers.

Claims System –

• Initiate new procedures to make claims processing more efficient.
• Coordinating with vendor to write and apply new processes.
• Creating business rules that enhance  workflow and support claim handling best practices.
• Perform regression testing on new  procedures as well as regular vendor upgrades.
• Informing claims staff of new  procedures and upgrades and assist in training if necessary.
• Update QA checklist for regression testing.
• Handling of inquiries regarding no coverage, no vehicle listed, etc from claims staff.

Accounting – 

• Handle daily and monthly balancing issues with coverage codes, paper transactions, suffix issues, payments or things done in error in the claims system by the handlers/examiners.
• Checking daily log of voids/stop pays from accounting are done in the claims express system. 
• Investigating uncashed claims checks  older than 6 months. Identifying the handler, follow up with handler to make sure it is voided in system as well as with accounting.
• Completion of check request for various claim item expenses.

Legal Exchange –

• Administrator for legal exchange –handling any issues with automatic jobs running.
• Responsible for adding new firm to legal exchange along with their rates.
• handling all emails and calls from law firms having issues with legal exchange and their budgets and invoices.
• Responsible for making sure vendors are coded correctly for legal exchange payment application.
• Running monthly reports for claims staff.

1099’s - 

· Making sure 1099 list is correct for processing and sending to Accounting. 

· Getting W9’s from vendors where there is no tax id. 

· Updating vendor file in address book maintenance. 

· Handling of calls from claim vendors after 1099’s are sent out.

Workers Compensation –

· Act as primary claim liaison with workers comp TPA Brentwood.

Claim File Reviews –

· Responsible for inputting and tabulating of quarterly file reviews for all claim examiner.

· Distribution of quarterly reports to claims staff.

Processing of Payment –

· Perform daily balancing of claim payments and investigate exceptions.

· Distribution of daily email to accounting to print checks.