WHAT DOES A CLAIMS ADJUSTER DO?
Published: Jun 02, 2025 - The Claims Adjuster maintains detailed documentation of claim activities, monitors hearing schedules, and prepares summaries for quarterly review meetings. This position evaluates and negotiates settlements, ensures compliance with company procedures, and refers cases to defense counsel when necessary. This role builds and sustains professional client relationships while providing support through field inspections and complex coverage analysis.
A Review of Professional Skills and Functions for Claims Adjuster
1. Claims Adjuster Duties
- Claim Investigation: Investigates, determines coverage of loss, and adjusts all elements of Property Loss claims of high severity
- Information Gathering: Corresponds with policyholders, claimants, witnesses, attorneys, etc., to gather important information to support contested claims in court
- Claims Oversight: Oversees and resolves truck, bus, commercial auto and/or public transportation claims, including litigation
- Counsel Management: Selects, oversees, and grades the performance of outside counsel
- Trial Monitoring: Attends and monitors trials to assess attorney performance and jury verdict risk
- Budget Negotiation: Sets and controls litigation budgets and negotiates outstanding settlements
- Accident Response: Initiates and oversees serious automobile accident investigations and rapid response
- Strategy Development: Develops strategies and effective plans that drive litigated matters/claims to better results
- Coverage Analysis: Accurately assesses and resolves commercial auto insurance coverage issues, analyzes facts and allegations in conjunction with all policy provisions, endorsements, and amendments
- Letter Drafting: Drafts, declination, Reservation of Rights, and other coverage letters
- Case Presentation: Presents case statuses/summaries in a clear, concise, and understandable manner
2. Claims Adjuster Details
- Claim Processing: Processes incoming claims based on established time frames and goals, utilizing company software.
- Coverage Research: Researches policy limits to determine coverage eligibility, determines the necessity for medical records, and verifies coverage based on past claims history.
- Team Support: Assists other processors and other departments within the company with claims-related questions.
- Record Collection: Contacts veterinary clinics to secure medical records and claim-related information.
- Medical Interpretation: Reads and interprets veterinary medical records and lab reports.
- Communication Documentation: Provides accurate and adequate documentation of all client and veterinary communication.
- Claim Review: Researches and reviews completed claims for accuracy and adjusts any errors based on supervisor approval.
- Customer Service: Provides “best in class” customer service to customers to discuss claims.
- Investigation Reporting: Prepares a report of findings of an investigation.
- Coverage Explanation: Explains coverage of loss.
- Equipment Operation: Operates standard office equipment/software including multi-line telephone system, facsimile machine, Excel/Spreadsheet, computer/printer, calculator, and photocopy machine.
3. Claims Adjuster Responsibilities
- Compensability Investigation: Investigates compensability issues, including recorded statements
- Compensability Determination: Determines compensability
- Form Filing: Files appropriate jurisdictional forms
- Payment Calculation: Calculates and issues indemnity payments
- Medical Approval: Approves medical payments on assigned claims
- Treatment Monitoring: Monitors medical treatment on claims assigned
- Claim Management: Provides proactive claim management
- Case Assignment: Assigns Nurse Case Managers and Vocational Specialists
- Denial Issuance: Issues denial letters to providers and claimants
- Record Review: Requests medical records and reviews medical
- Vendor Communication: Communicates with various vendors and attorneys
- Status Reporting: Communicates status reports to the employer and excess carriers
- Claim Recommendation: Makes recommendations regarding claim handling and resolution
4. Claims Adjuster Job Summary
- Diary Maintenance: Maintains a diary on all open claims
- Hearing Attendance: Attends hearings, trials, and mediations
- Summary Preparation: Prepares claim summaries for quarterly claim review meetings with employers
- Meeting Participation: Attends quarterly claim review meetings with employers
- Claim Referral: Refers claim to defense counsel
- Date Monitoring: Monitors Hearing date and consideration date logs
- Settlement Negotiation: Evaluates and negotiates stipulations and settlements
- Client Relations: Develops and maintains professional relationships with assigned clients
- Standards Compliance: Adheres to SISCO standards and procedures
- Activity Documentation: Documents claim activity in the claim processing system
- Field Support: May provide field adjuster support at the claimant’s site with visual inspections
- Coverage Review: Reviews complex coverage analysis and provides work-up for approval
5. Claims Adjuster Functions
- Call Handling: Answers and directs incoming calls
- Claim Processing: Receives, researches, processes, and responds to household goods claims
- Customer Communication: Communicates with customers, both verbally and in writing, regarding the status of a claim
- Record Maintenance: Creates, updates, and maintains claims-related records
- Form Completion: Completes Notice of Claim forms based on claim settlements
- Appointment Scheduling: Schedules appointments with customers and inspectors/repairers
- Administrative Support: Provides other clerical and administrative support to staff
- Claim Review: Reviews claim information and other records to ascertain the completeness and validity of the claim
- Damage Oversight: Oversees the arrangement, inspection, and repair of damaged goods
- Contractor Monitoring: Monitors the performance of contractors to ensure that the repair is performed satisfactorily and in a timely manner
- Claim Correspondence: Corresponds with all parties involved in the settlement of the claim
- Claim Calculation: Computes and calculates the amount of the claim and ensures the claimant is paid the amount due according to the settlement agreement and company procedures
- Liability Determination: Determines which carrier is liable for damage to the shipment and prepares a claims package with the invoice and all documentation to support the settlement