CLAIMS SPECIALIST JOB DESCRIPTION

A Claims Specialist handles exactly what no one else in a P&C or multi-line insurance operation owns outright: the file from first notice of loss through reserves, coverage determination, and final settlement. Across general liability, auto, professional liability, and property lines, this role applies policy language to real-world facts of loss and must reach defensible conclusions within delegated authority limits. Reserve adequacy and subrogation recovery rates follow this person directly. The role sits within the claims department, working alongside special investigations units, defense counsel, and third-party administrators.

As the Claims Specialist, you investigate, evaluate, and negotiate insurance claims across assigned lines of business, ensuring reserves are set accurately and files are resolved within authority thresholds and compliance requirements. You operate within a structured claims unit, collaborating with underwriting, legal counsel, and external vendors while reporting to a Claims Team Leader or Claims Manager.

Career Impact: Developing technical expertise across multiple insurance lines, including general liability, auto, and professional liability, positions you for advancement into senior adjuster, claims lead, or coverage counsel roles within the P&C market.

Business Impact: Accurate reserve-setting and timely file resolution directly protect the organization's combined ratio and ensure policyholders receive fair outcomes under complex, multi-line policies.

Growth Opportunity: Hands-on exposure to litigation strategy, ADR, and coverage letter drafting builds the specialized competency set that qualifies candidates for AIC, CPCU, or law-degree-adjacent tracks in claims management.

• Investigate assigned claims by reviewing policy terms, evaluating coverage, and documenting facts of loss to reach a defensible liability determination.
• Negotiate settlements within delegated authority limits, coordinating with defense counsel, insureds, and claimants to achieve timely and cost-effective resolutions.
• Set and adjust reserves according to established best-practice guidelines, recommending special reserves when file complexity warrants escalation.
• Prepare coverage letters addressing relevant policy provisions and exclusions for each assigned claim file.
• Partner with the Special Investigations Unit and subrogation team to identify fraud indicators and recovery opportunities on assigned caseloads.
• Monitor litigation strategy and budgets on files in suit, maintaining financial controls through regular counsel communication.
• Produce internal reports and metrics on file status, reserve movements, and emerging liability trends for claims leadership.
• Collaborate with underwriting, reinsurers, and external vendors to ensure coordinated, compliant handling of complex or excess-layer claims.

• Bachelor's degree in business, finance, law, or a related field, or equivalent work experience.
• 3 or more years of insurance claims adjusting experience, with demonstrated exposure to at least one of the following lines: general liability, auto liability, property, or professional liability.
• Working knowledge of coverage analysis, reserve-setting practices, and claims documentation standards applicable to P&C lines.
• Demonstrated ability to independently negotiate and resolve claims within delegated authority and within compliance requirements.
• Familiarity with subrogation principles, third-party administrator oversight, and litigation file management.
• Certification in a recognized insurance program such as AIC or documented progress toward CPCU, or willingness to complete the program.
• Strong written and verbal communication skills, including the ability to draft coverage letters and present findings to senior management and external stakeholders.
• Valid driver's license and ability to meet company driving and background check requirements.

• Law degree or paralegal background, particularly for professional liability or D&O/E&O claim assignments.
• Prior experience managing multi-line or excess/surplus lines files, including coordination with reinsurers or co-insurers.
• Advanced analytical skills including financial analysis fundamentals and an understanding of accounting principles as they apply to reserve adequacy.
• Experience working with third-party administrators and established vendor panels across multiple jurisdictions.

• Reserve adequacy ratio, measuring whether set reserves align with ultimate settlement outcomes across the caseload.
• Average days to resolution per file, tracking timely closure relative to department benchmarks and policy service standards.
• Subrogation recovery rate, reflecting how effectively recoverable amounts are identified and pursued on closed files.
• Litigation budget variance, measuring how closely managed files track against counsel-agreed cost controls.
• Coverage dispute rate, indicating the proportion of files requiring formal coverage letters or declinations and the accuracy of determinations made.
• Typical tools: Claims management systems (commonly Guidewire, Duck Creek); document management (commonly Salesforce, SharePoint); office productivity (commonly Microsoft Excel, Word).

• Base Salary Range: $55,000-$85,000 annually, varying by line of business and seniority
• Bonus: Performance-based annual bonus, typically 5-12% of base salary
• Equity: Rarely offered at this level; occasional RSUs at larger carriers
• Health Benefits: Medical, dental, and vision; employer contribution typically 70-80%
• PTO: 15-20 days annually, plus standard federal holidays
• Common Perks: CE reimbursement for AIC/CPCU coursework, hybrid work eligibility after onboarding, mileage reimbursement for field inspections

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment is contingent on successful completion of a background check, which may include a review of criminal history and, for roles with financial authority, credit history. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected under applicable federal, state, and local law. Applicants requiring a reasonable accommodation to participate in the hiring process should notify the recruiting team at any point during the process. Candidates must be authorized to work in the United States.

The Claims Specialist owns the accurate distribution of child care payments and reporting of ancillary payment data within a government-administered child care services operation. Working alongside county staff, child care providers, and payment agencies, the Claims Specialist delivers payment accuracy and audit-ready records that enable families to access subsidized care.

Key Responsibilities

• Identify proper forms and obtain signatures on all required forms and documentation.
• Establish and maintain good working relationships with partners, including CalWORKs participants.
• Support county staff, child care providers, and Stage 2 and 3 child care payment agencies.
• Provide monthly reporting statistics to supervisor for designated area of responsibility.
• Enter manual provider timesheets and invoice information accurately.
• Reconcile and troubleshoot timesheet and transaction reports.
• Create and maintain adequate budget files for clients for audit purposes.
• Monitor accuracy and timeliness of payment processing.
• Enter budget information and verify that invoices received are budget-authorized.

Education & Experience

• High School Diploma required; Bachelor's Degree preferred.
• Experience in accounting or a related background is an asset.
• Knowledge of modern office methods, practices, and record-keeping systems.
• Demonstrated ability to use various computer systems, preferably CalWIN and KinderTrack.
• Proficient with Microsoft Excel and basic working knowledge of Microsoft Access.
• Ability to recognize and maintain the confidentiality of all materials in the work setting.
• Strong verbal and written communication skills with proper customer service etiquette.
• Excellent accuracy and attention to detail, with the ability to prioritize work and meet deadlines.
• Able to establish and maintain professional relationships with community partners and providers.
• Able to work independently with minimal supervision and manage multiple projects simultaneously.

Reporting to management, the Claims Specialist investigates and resolves discrepancy cases, processes credits, and tracks cargo claims through settlement within a logistics and supply chain environment. Partnering with the credit and collection team, 3PL carriers, and insurance contacts, this role delivers timely claim closures and accurate reporting that protect the organization's financial position.

Primary Duties

• Investigate, review, and validate discrepancy cases to process credit to the customer.
• Communicate with the credit and collection team to ensure all deductions are disputed or credited correctly.
• Resolve claims and verify disputes and denials by communicating with 3PL carriers.
• Ensure claim cases are settled and closed in a timely fashion.
• Prepare and submit claimable cases to insurance, and track each case through settlement, including communications with insurance for cargo claims.
• Monitor 3PL performance, assisting in claim creation and recovery.
• Prepare daily and weekly reports for management.

Skills & Qualifications

• Bachelor's degree in Logistics, Supply Chain, Business, Finance, or a similar field.
• 2 to 3 years of relevant experience in business or logistics.
• Expertise with SAP.
• Experience using advanced supply chain management, enterprise planning, or financial planning systems.
• Advanced Excel and PowerPoint skills.
• Ability to read, prepare, interpret, and understand product shipment information from various order and shipping documents.
• Excellent oral and written communication skills.
• Able to collaborate with various departments and customers, adapting in a fast-paced environment.

Sitting at the intersection of risk management and carrier operations, the Claims Specialist builds a coordinated cargo claims process by managing filings, collecting documentation, and working directly with insurance claim adjusters to mitigate loss and exposure. Operating across broker, customer, and carrier relationships and reporting to the Operations Manager, this role shapes the organization's risk outcomes through accurate claim tracking, trend identification, and training support for the sales team.

Duties

• Process cargo claims arising from carrier service issues such as temperature abuse, cargo theft, and incorrect or damaged product at delivery.
• File claims through carrier insurance and manage each claim through to completion.
• Record claims upon initial notification in the claims management system.
• Work with the Accounts Payable team to process and collect payments.
• Collect necessary claim documents to process and substantiate each case to mitigate loss and exposure.
• Assist with customer payment and overall satisfaction throughout the claim process.
• Develop claims training material and facilitate training sessions for the sales team.
• Identify trends and problem areas to mitigate risk and future loss.
• Provide reporting to management as requested and maintain accurate claim tracking.

Requirements

• High school diploma or GED required; Bachelor's Degree in Business, Supply Chain, or a related field preferred.
• Experience in the transportation or logistics industry, or experience processing claims.
• Familiarity with Carmack and commercial cargo insurance.
• Working knowledge of transportation management software.
• Basic knowledge of Microsoft Office.
• Ability to understand the application of carrier and customer contracts.
• Analytical and investigative mindset with strong negotiation skills.
• Able to manage multiple tasks in a time-sensitive environment and escalate issues as needed.

Embedded within a specialized aviation claims unit, the Claims Specialist III develops deep technical expertise across coverage determination, liability investigation, and litigation budgeting for aviation-related claims. Working closely with defense counsel, vendors, insureds, and internal and external customers, this role delivers sound, data-driven claim resolutions while balancing competing stakeholder needs with a consistent risk mindset.

Core Functions

• Determine the scope and extent of available coverage.
• Re-evaluate coverage as warranted.
• Prepare and execute investigation strategies that identify critical issues affecting liability, causation, and damages, and consider opportunities for third-party contribution.
• Independently negotiate claims after obtaining the appropriate authority.
• Document evaluation, thought process, and strategy.
• Utilize ADR as appropriate and necessary.
• Strategize and budget the litigation of each claim through discussions with counsel, vendors, and insureds.
• Establish clear ground rules with defense and coverage counsel to maintain financial control of budget and expenses.
• Make regular and appropriate contact with internal and external customers.
• Give guidance to insureds and brokers to manage expectations.

Qualifications & Experience

• Bachelor's degree or higher required.
• 5 or more years of insurance claim adjusting experience, with aviation experience strongly preferred.
• Knowledge of first and third party insurance coverage, via experience or education.
• Proficient with common and specialized claims systems, programs, and applications.
• Strong decision-making and negotiation skills.
• Ability to explain technical issues clearly and problem-solve effectively.
• Ability to speak in public forums to current and prospective clients.
• Excellent interpersonal and written communication skills.
• Able to manage time, prioritize projects, and work with minimal supervision.

A key member of the Issue Resolution Team, the Claims Specialist leads the investigation, negotiation, and resolution of cargo claims while applying knowledge of federal regulations governing the transportation industry. Collaborating across internal carrier sales, customer operations teams, legal counsel, and external adjusters, this role delivers timely settlements and accurate claim tracking that protect both customers and carriers.

Functions

• Enter and track claims in the claims management system.
• Analyze data to determine a claim's validity.
• Notify involved parties of claim filings and rejected claims.
• Determine next steps and order inspections to support claim resolution with the customer or carrier.
• Evaluate independent reports, including video, written incident reports, and valuation estimates, in claim resolution.
• Negotiate timely settlements and claim resolutions, process payment requests, and complete final case paperwork following discussion with customers, carriers, and appropriate personnel.
• Escalate and collaborate with claims leadership, legal counsel, and external adjusters as needed.
• Collaborate cross-functionally with internal carrier sales and customer operations teams.

Position Requirements

• 6 months or more of freight or insurance claims experience preferred.
• Knowledge of DOT and other federal regulations applicable to the transportation industry.
• Familiarity with claims software preferred.
• Prior experience negotiating or mediating payment disputes preferred.
• Proficient in Microsoft Office including Outlook, Word, and Excel.
• Excellent written and oral communication skills.
• Able to prepare reports and interpret complex material, statistical data, and results for management.
• Flexible and able to adapt to change with new systems and methods, managing multiple priorities in a fast-paced environment.

Accurate resolution of total loss and GAP claims for dealers, lien holders, and customers depends on the Claims Specialist, who owns coverage verification, cash value calculation, and payment facilitation across the full claims workflow. Based within the claims department and serving as a technical advisor to customer service specialists, this role shapes claim outcomes by applying deep knowledge of retail installment contracts, F&I protocols, and lending institution guidelines.

Accountabilities

• Adjust and process claims from dealers, lien holders, and customers accurately and efficiently.
• Verify contract information and determine coverage for the vehicle specified on each claim.
• Determine validity and reason for total loss with proper documentation.
• Establish the claim process and communicate with customers within the contract-allotted time.
• Work with customers, lien holders, and insurance companies to obtain required documentation.
• Calculate actual cash values, verify limits of liability, and determine actual payoff from additional charges and late fees.
• Calculate GAP payoff and facilitate payment to the correct party.
• Mediate interdepartmental cancellations and paper flow.
• Coordinate and communicate actions within the organization and with dealers.

Knowledge, Skills & Abilities

• Knowledge of retail installment contracts, F&I procedures and protocols, insurance guidelines, and lending institution collections.
• Knowledge of claims productivity measurements and claims administration best practices.
• Knowledge of the organization's products, their coverage, and associated benefits.
• Strong analytical and problem-solving skills with the ability to act as a technical advisor.
• Proficient with computer systems, including the ability to operate under pressure.
• Excellent customer service and negotiating skills, with the ability to handle customers in difficult situations.
• Strong oral and written communication skills.
• Able to support change and adapt to evolving processes and requirements.

As the Claims Specialist, this role delivers end-to-end administrative support across claims intake, file management, and policyholder correspondence within the claims department, serving policyholders, brokers, claimants, underwriters, and internal claims staff. The claims department relies on this work to ensure all new claims are established correctly in the appropriate systems and that all insured and broker communications are completed accurately and on time.

Operational Focus

• Provide administrative support for the claims department, including claims intake and setup, scanning, mail delivery, incoming payments, telephone inquiries, filing, and closed file management.
• Ensure all new claims are set up correctly in the appropriate systems, including policy information, coverage, insurer, and loss details.
• Ensure all correspondence, including follow-up emails and responses, is completed in a timely manner with insureds and brokers.
• Administer claim records and files in both paper and electronic formats.
• Liaise with Underwriting as required.
• Complete all other administrative and service duties within the claims department as assigned.

Required Qualifications

• Bachelor's Degree, College Diploma, or equivalent training.
• 1 or more years of related industry or claims experience is an asset.
• Proficient in Microsoft Word and Excel, and comfortable learning various computer systems and managing electronic files.
• Good organizational skills and attention to detail.
• Strong prioritization and decision-making skills.
• Strong interpersonal, presentation, and communication skills, both oral and written.

Claims Specialist delivers organized preparation and daily submission of insurance claims while supporting cross-functional teams in identifying risks and resolving accounts receivable denials. The work directly supports leadership in implementing procedure changes and maintaining consistent claim quality across the department.

Key Deliverables

• Organize and prepare insurance claims for daily submissions.
• Review required documentation.
• Research how to properly submit claims.
• Communicate and work with clients and cross-functional departments to identify potential risks and solutions for performance improvement.
• Assist leadership with implementation of procedure changes.
• Assist with special projects and compile reports.
• Respond to inquiries regarding accounts receivable denials and processes.
• Manage workload and complete assignments on time.

Minimum Qualifications

• Bachelor's or Associate's Degree in Business or Finance preferred but not required.
• Capable user of Microsoft Office products including Outlook, Excel, and Word.
• Excellent written and verbal communication skills.
• Detail-oriented with the ability to plan, organize, and complete tasks on time.
• Self-starter who takes initiative to overcome challenges and can work independently and manage multiple tasks.

The Claims Specialist owns the full lifecycle of property and merchandise claims, from initial data gathering through resolution, while producing weekly and monthly metrics and reporting for management and location managers. Working with clients, independent contractor owners, billing and account managers, and a network of repair vendors, this role delivers timely claim closures and data-driven insights that reduce aged claim exposure.

Role Responsibilities

• Serve as point of contact for all property and merchandise claims.
• Gather initial claim data from clients, location managers, and independent contractor owners, and record it on the ongoing claims log.
• Initiate contact with clients to obtain information regarding the claim and follow through until the claim is accepted or denied.
• Establish open working relationships with independent contractor owners to promote timely resolution of open claims.
• Complete claim forms and track claim status from start to finish, including payment processing.
• Attend monthly meetings with Billing and Account Managers to review open claims and escalate resolution of aged claims.
• Create and maintain SOPs documenting claims processes.
• Prepare weekly and monthly metrics and reporting for distribution to applicable parties.
• Develop and maintain a database of repair companies that customers can reference to secure a repair contractor.

Background & Experience

• High school diploma or equivalent required; college degree in business preferred but not required.
• 3 years of claims processing experience.
• Experience in a 3PL environment or transportation industry is an asset.
• Experience in invoicing, accounts receivable, accounts payable, and customer service is an asset.
• Advanced proficiency in Microsoft Excel and all Microsoft Office applications.
• Ability to process, develop, and analyze data accurately and on time.
• Demonstrated strong organizational and time management skills.
• Strong written and verbal communication skills, with the ability to work across all levels of staff and management.
• Professional and courteous demeanor with the ability to manage multiple tasks and deadlines independently.

Reporting to claims leadership, the Claims Specialist produces timely submission and compliant processing of insurance and third-party claims across pre-adjudication, follow-up, facility, and professional claim types for both commercial and government payers. Working with payors, internal teams, and management, this role delivers denial resolution and process improvement recommendations that strengthen cash flow and support patient satisfaction.

Day-to-Day Responsibilities

• Analyze claim denials, work with payors to resolve denials, and track all denials by payor and denial category to identify recurring trends.
• Recommend process improvements or system edits to eliminate future denials.
• Review and analyze claim denials to perform the appropriate appeals necessary for reimbursement.
• Research denied claims and determine appropriate appeal steps.
• Collect required documentation, review file documentation, and request any missing items needed.
• Ensure all claim documentation is complete, accurate, and compliant with policy, and update files, databases, and records for recurring internal reports.
• Research and re-bill unpaid claims and resolve accounts on follow-up reports.
• Correct errors on electronic error reports using all available information.

Education & Experience

• Associate's degree in billing, coding, business, finance, or a related field preferred.
• 2 to 4 years of billing, coding, business, or finance-related experience required.
• Knowledge of commercial and government payer requirements and claim submission regulations.
• Strong research skills with the ability to make appropriate decisions to maximize reimbursement on accounts.
• Able to identify current and potential billing issues related to outstanding receivables.
• Able to participate in meetings addressing trends in denials or unprocessed claims.
• Strong attention to detail with the ability to manage multiple priorities and meet deadlines.

Embedded within a claims team responsible for medical, dental, vision, and short-term disability benefits administration, the Claims Specialist shapes the member experience by processing claim adjustments, appeals, vendor invoices, and case management claims with a high degree of accuracy and urgency. Working closely with third parties and team members to obtain outstanding balances and report monthly claims metrics, this role delivers the processing quality that clients depend on for their members' benefits journey.

Job Functions

• Research and process claim adjustments, returned checks, refunds, and stop payments accurately and promptly.
• Process priority claims and vendor invoices.
• Respond to appeals and correspondence regarding claims functions.
• Partner with third parties to obtain payment on outstanding balances.
• Provide monthly reporting on claims metrics.
• Process case management and utilization review negotiated claims.
• Identify potential subrogation claims.
• Support team members and assist where needed.

Professional Experience

• High school diploma, Associate's Degree, or equivalent required.
• 5 or more years of claims processing experience.
• Knowledge of medical, dental, vision, and short-term disability claims handling.
• Impeccable attention to detail with a high degree of accuracy and urgency.
• Strong interpersonal and communication skills.
• Able to take initiative and work independently with minimal supervision while maintaining a team-oriented approach to problem-solving.

Sitting at the intersection of claims investigation and legal compliance, the Claims Specialist leads resolution of General Liability, Auto Liability, and Property claims through direct investigation, coverage evaluation, and negotiation within defined authority and procedural standards. Operating within the claims department and providing oversight to the Third Party Administrator on assigned files, this role shapes claim outcomes that protect the organization's financial and legal standing.

Strategic Responsibilities

• Investigate, negotiate, and resolve General Liability, Auto Liability, and Property claims as assigned.
• Provide oversight and direction to the Third Party Administrator on assigned files.
• Adhere to claims handling procedures including claim documentation, reserves, and task and diary management.
• Work within the department to ensure development and compliance of Safety, Education, and Training Programs.
• Comply with applicable federal, state, and local laws, rules, and regulations, and follow all company policies and procedures.
• Maintain regular and punctual attendance at work and meetings.

Qualifications & Experience

• Bachelor's Degree or equivalent combination of demonstrated related experience.
• Certification in a recognized insurance program such as Claims Law Associate or AIC, or documented progress toward the designation.
• Minimum of 2 years of experience adjusting insurance claims in general liability, automobile liability, or property claims handling.
• Working knowledge of accounting principles and financial analysis is preferred.
• Advanced analytical skills preferred.
• Proficient in Microsoft Office Suite at an intermediate to advanced level.
• Excellent verbal and written communication skills, including interpersonal and presentation skills.
• Proficiency in English sufficient to perform job duties and communicate with employees and vendors.
• Valid Driver's License in compliance with company driving policies.

A key member of the Data Analytics Operations team, the Claims Specialist leads the design, implementation, and ongoing management of seriatim data governance processes that ensure a single, accurate source of client data for downstream valuation, experience analysis, and administrative use within a life reinsurance organization. Collaborating across IT, data stakeholders, and all levels of management, this role builds the data integrity infrastructure that the business unit relies on for integrated reporting and talent development.

Leadership Responsibilities

• Lead and execute seriatim data governance processes and procedures to ensure maintenance and accuracy of a single source of recurring seriatim data for downstream valuation, experience analysis, and administrative purposes.
• Facilitate regular governance committee meetings, provide input materials, track committee decisions, and communicate outcomes to appropriate stakeholders.
• Interact with partners in the Data Analytics Operations team, IT, and other stakeholders to enhance the content, quality, and reliability of seriatim data.
• Support the Data Analytics Operations team in delivering analysis and reporting through the application of business subject matter expertise and technical competency.
• Recruit, train, and mentor team members to ensure delivery of production and department goals, and identify opportunities for talent development.
• Collaborate with stakeholders to identify and prioritize work assignments supporting the business unit's reliance on accurate, integrated seriatim client data.
• Participate in projects as assigned and assume leadership roles as required to achieve project critical success factors.

Experience & Qualifications

• Bachelor's degree in accounting, finance, mathematics, computer science, or a related field, or equivalent experience.
• Minimum of 7 years of life reinsurance operations experience.
• Minimum of 5 years of leadership, management, or project management experience.
• Strong understanding of client seriatim reporting, data transformation, and seriatim data utilization within a life reinsurance organization.
• Advanced analytical and problem-solving skills.
• Proficient in Excel and SQL.
• Experience in database environments and ability to acquire additional technical skills as required.
• Advanced stakeholder management skills and experience.
• Able to understand complex issues and manage them to successful closure to meet stakeholder requirements.
• Professional oral and written communication skills, with the ability to collaborate across all levels of the organization.

Effective resolution of D&O, E&O, fiduciary liability, and employment practices liability claims delivers the financial and reputational protection that policyholders depend on, and the Claims Specialist owns that outcome by setting case strategy and managing litigation in partnership with claims leadership and regional practice leaders. Serving as the primary liaison to internal and external counsel, brokers, reinsurers, and vendors, this role shapes reserve accuracy and emerging trend reporting across multiple lines of professional liability business.

Scope of Work

• Manage assigned professional liability claims across multiple lines of business by setting case strategy in partnership with claims leadership.
• Partner with internal and external counsel to set and pursue effective and cost-efficient litigation strategies for claims in litigation.
• Produce internal reports and ensure that reserves are set according to best practice guidelines.
• Coordinate and manage communications with internal colleagues and key external stakeholders including clients, brokers, reinsurers, and vendors.
• Prepare coverage letters addressing relevant policy provisions for each assigned claim.
• Identify, monitor, and report on emerging liability and coverage trends.

Technical Qualifications

• Law degree required.
• 3 or more years of professional liability claims handling experience preferred.
• Experience managing all facets of claim files, including analysis, investigation, evaluation, presentation, and negotiation.
• Knowledge of D&O, E&O, fiduciary liability, and employment practices liability policy structures and coverage provisions.
• Skilled in building and maintaining effective working relationships with insureds, brokers, underwriters, co-insurers, excess carriers, reinsurers, and external vendors.
• Excellent verbal and written communication, negotiation, analytical, and presentation skills.
• Proactive approach to tasks with the ability to prioritize multiple work streams without sacrificing accuracy.
• Intellectually curious with a commitment to continuously improving technical claims knowledge.
• Demonstrated professionalism and integrity in handling claims responsibilities.
• Willing to travel up to 10% of the time.

As the Claims Specialist, this role delivers prompt and equitable resolution of assigned claims across multiple property casualty insurance lines, applying best claims practices and delegated authority with minimal oversight. The claims department relies on this work to maintain reserve adequacy, identify fraud and subrogation opportunities, and sustain an outstanding customer service experience for policyholders, agents, and claimants' attorneys.

Areas of Ownership

• Initiate and conduct follow-ups and maintain proficiency in the use of claims systems and related business systems.
• Verify proper policy coverages and apply best claims practices to conclude assigned cases per company guidelines.
• Open, close, and adjust reserves according to established practices to ensure reserve adequacy, and recommend special reserves where necessary.
• Maintain current knowledge of multiple insurance lines, court decisions, current claims guidelines, and policy changes and modifications.
• Submit administrative reports as needed.
• Partner with the Special Investigations Unit and Subrogation to identify fraud and subrogation opportunities, and assist or prepare files for lawsuits, trials, or subrogation.
• Deliver an outstanding customer service experience to all internal and external customers.

Skills & Qualifications

• Knowledge of insurance company operations and multiple property casualty insurance lines of business.
• Knowledge of insurance contracts and the legal aspects of court procedures affecting legal liability across all lines of insurance.
• Experience in claims systems and best claims practices.
• Experience with material and physical damage repair processes, vendor management, and customer service techniques.
• Validated analytical skills for applying coverage, policy exclusions and exceptions, and laws of jurisdiction to investigate facts.
• Proven ability to establish repair requirements and cost estimates for extensive losses.
• Proven organizational skills to effectively prioritize complex and sophisticated workloads.
• Demonstrated leadership capabilities to train, coach, and mentor less experienced associates.
• Excellent written and verbal communication skills, with the ability to collaborate with policyholders, claimants' attorneys, agents, and the general public.
• Able to operate a personal computer and related software.

Claims Specialist handles inbound claims calls and administers motor vehicle and contents claims end-to-end, from identifying insured events and making coverage determinations to liaising with repairers and settling claims within policy requirements and the Insurance Code of Practice. Success in the position means maintaining accurate cost control throughout each claim, resolving complaints in accordance with company guidelines, and consistently identifying potential fraud and recovery indicators across the managed caseload.

Work Activities

• Receive and action inbound claims calls.
• Lodge motor vehicle claims and administer claims end-to-end.
• Identify insured events and clearly explain relevant exclusions upfront.
• Underwrite claims accurately and make determinations on cover.
• Seek additional information to validate events and ownership.
• Liaise with repairers to organize make-safe and restoration works, quotes, and repairs.
• Make determinations on cover based on specialist report findings.
• Validate and complete fair and reasonable assessments on contents items.
• Monitor and control claim costs throughout the claim, including progress payments, variations, and specialist fees.
• Review scope of works to ensure accuracy and alignment with policy.
• Process invoices accurately for timely payment to service providers.
• Settle claims in a timely manner through continuous follow-up and member updates.
• Comply with the Insurance Code of Practice and other relevant legislation, regulations, and policy requirements.
• Resolve complaints in accordance with company guidelines.
• Identify potential fraud and recovery indicators on applicable claims.

Background & Experience

• Previous claims experience required.
• Strong communication skills, both written and verbal, with ability to build rapport quickly using a firm, engaging, and respectful telephone manner.
• Effective problem-solving skills with active listening and ability to question effectively.
• Ability to influence and educate to gain acceptance of ideas.
• Highly developed planning, organization, and time management skills with ability to work on own initiative.
• Strong administration skills with the ability to work well under pressure.
• Able to prioritize workload and make timely decisions to manage files accordingly.
• Flexible and receptive to change, with a team-oriented approach focused on driving personal and shared outcomes.

The Claims Specialist owns accurate and timely investigation of claims and deductions across OS&D, pricing, coupon, and promotional deduction types, triggering approval and resolution workflows and maintaining deductions balance targets within the organization's Bill to Cash process. Collaborating with Finance, Sales, and local Operations to recover invalid claims and resolve disputes, this role builds the cross-functional data accuracy that protects revenue and supports continuous process improvement.

Performance Expectations

• Conduct accurate and timely claim investigation by identifying relevant documentation for each claim type.
• Escalate invalid claims to Collections where amounts are collectable.
• Proactively flag accrual gaps in SAP rebate agreements.
• Assist with automated claim registration and validation, and manually process claims, including collating backup documentation when tools are unavailable.
• Trigger approval workflows according to claim status and follow up as necessary.
• Trigger resolution workflows to the appropriate parties when resolution is not automated.
• Send customer resolution communications along with necessary documentation.
• Resolve claims and deductions within the required turnaround time.
• Follow the defined critical issue matrix and raise alerts whenever required.
• Maintain regular contact with Finance, Sales, and local Operations to resolve disputes and recover invalid claims.
• Follow up with various departments to obtain supporting documents for dispute and deductions resolution.
• Maintain overall deductions balance targets as required by the organization.

Experience & Qualifications

• Bachelor's degree, preferably in Accounting or a related field.
• Experience in Disputes Management with overall Bill to Cash knowledge and understanding required.
• Exposure to the consumer goods industry and retail promotions is an asset.
• Knowledge of claim and deduction types, including OS&D, Pricing, Coupon Deductions, and Promotional deductions.
• Accounting skills, including budgeting, forecasting, and reconciliations.
• Proficient in Microsoft Office suite and automated deduction tools.
• Experience with customer business and trade term tools such as Anaplan and SAP.
• Exposure to technologies such as Pega and HighRadius is an asset.
• Strong analytical skills and attention to detail with the ability to identify issues proactively and troubleshoot promptly.
• Customer-centric mindset with ability to challenge the status quo and drive efficiency improvements.
• Excellent communication, influencing, and interpersonal skills; English proficiency at B2 level or above.
• Self-motivated and independent with strong problem-solving skills and a proactive approach.
• Able to work flexibly across shifts as required.

Reporting to the Claims Team Leader or manager, the Claims Specialist investigates and settles a substantial caseload of commercial and recreational marine claims, including coverage evaluation, reserve-setting, and attendance at settlement conferences and mediations. Working closely with claims leadership, vendor management, and the broader claims organization, this role delivers measurable process improvements, quality-driven training materials, and technology-enabled efficiency gains that improve the claims experience for all parties.

Ownership Areas

• Handle a substantial caseload of commercial and recreational marine claims on a day-to-day basis.
• Receive assignments, review claim and policy information, and evaluate coverage issues, including drafting coverage letters.
• Attend settlement conferences and mediations.
• Set reserves within authority limits.
• Analyze and measure the effectiveness of existing claims processes and develop sustainable, repeatable, and quantifiable process improvements, including building and maintaining process maps and documentation.
• Design claims processes focused on eliminating waste and improving data quality, and train the claims team to execute these processes.
• Collaborate with claims leadership to design, test, and launch technology solutions to drive claims efficiency and improve the claims experience.
• Drive quality file handling by identifying opportunity areas in process, compliance, and execution, and provide coaching and feedback to improve performance.
• Develop, maintain, and modify training materials for use within the claims organization, tailoring content to targeted audiences.
• Identify quality opportunities with external partner files and develop remediation plans in collaboration with vendor management to improve quality and performance.

Qualifications & Experience

• Law degree preferred.
• Quality assurance or training experience preferred.
• Certification in a recognized insurance designation such as SCLA, AIC, or CPCU is beneficial.
• 3 or more years of experience in insurance claims, involving auto, physical damage, or bodily injury claims, with leadership experience preferred.
• Marine claims experience preferred, with background in boat and yacht construction, operation, repair methodology, and salvage beneficial.
• Experience working in a technology or start-up environment is an asset.
• Proficient in Microsoft Word, Excel, and Outlook, with proficiency in Google Sheets preferred.
• Proficiency in designing processes and creating flowcharts.
• Strong analytical skills with a detail-oriented approach.
• Strong communication, presentation, and negotiation skills, including the ability to listen effectively and present written communication to varied audiences.
• Excellent interpersonal skills with the ability to establish trust and effective working relationships internally and externally.
• Able to work collaboratively, independently, and as part of a team, with the ability to multitask and adapt in a changing environment.
• Willing to travel and relocate as required.