Claims Specialist

Receives new claim assignments, analyzes the nature of the claim/loss to determine required investigation and handling.  Determines and identifies coverage issues or questions of claim compensability. 

Is responsible for direct handling Medical-only, Complex Medical-only claims in full compliance with Special Claim Handling Requirements & MSMM Claim Handling Guidelines.  Claim handling responsibilities also involve frequent and professional claim handling interaction with the Customer, Injured Workers, and Medical Personnel and the Insurance Broker.    

Conducts an investigation to collect all necessary information for assigned claims and appropriately evaluates completed investigation and case facts to determine merits of each claim.  Requests job process investigations from MSMM staff who are on-site at the respective Toyota/MTMUS Plants where indicated. Participates in Complex Case Meetings in full compliance with Special Claim Handling requirements by plant affiliate location.  

Initiates reserve changes within assigned authority, makes recommendations to supervisor manager where assigned authority is exceeded.    

Ensures IVOS organizational claim coding, Medgate/Cority Number, and the Injured Worker’s Employee Clock Number are timely and accurately updated in IVOS to support data sharing requirements with Toyota/MTMUS.  

Timely/ appropriately reports WC cases to the Claims Manager that will require Reserve Consultation Review at required thresholds with the Customer (arising reserves and reserve increases), to ensure compliance with Special Claim Handling requirements by plant affiliate location.  

Is fully complaint in completing WC Claim Summaries on assigned cases as required and is a capable presenter in scheduled virtual meetings with Toyota, MTMUS, TMNA and Aon LA.  

Manages, controls and negotiates timely and equitable claims payments and settlements in accordance with jurisdictional and fair claims practices requirements and Company policy and Special Claim Handling requirements. 

Maintains diary and ensures appropriate claims system documentation as required by company claim manuals and procedures.  May be responsible for submission of claim forms and reports required by outside agencies. 

Investigates and evaluates recovery potential.  Performs all necessary recovery activities. 

Reports to Claims Manager regarding all new and continuing developments on claims being reportable to MSMM Home Office under published guidelines. 

Ensures compliance with all adjuster licensing regulations and requirements. 

Services the claim needs of our customers including insureds, claimants, brokers, etc., in accordance with company policy and procedures, and attends client visitations with underwriters and other parties to conduct presentations and reviews. 

Maintains ongoing communication with all customers throughout the claims process in an effort to provide timely and appropriate claim status as appropriate and/or required by statutory regulations. 

Completes timely and accurate data reports to state reporting agencies to ensured full compliance with MSMM and regulatory requirement. 

Maintains full compliance with all regulatory Fair Claim Practices Acts and state and federal regulations. 

Maintains full compliance with all state licensing and continuing education requirements to ensure current and appropriate filing/standing of all adjuster licenses. 

High School Degree or G.E.D. is required. Bachelor's degree (B. A.) is preferred.  

3+ years of claims experience, including ability to successfully negotiate settlements, verify coverage, appropriately set reserves, successfully complete investigations and understand rules associated with state regulations