Role Purpose

The Accident and Health Claims Adjuster is responsible to handle, investigate, analyze, calculate and approve  insurance claims filed by policyholders and determine the extent of insurance company's liability concerning Accident and Health claims. 

 

Key Responsabilities

Manage, evaluate and adjust Accident & Health claims as per the policy terms and conditions including application of exclusions if applicable.Work and manage as many fast track claims as possible (Medical Expenses) and analyze medical records.Assist in resolving complaints from policyholders relative to claims.Comply with OCS, PMP objectives, Claims Best Practices guidelines & standards of services as required.Do coverage determination position letters to policyholders.Perform specials projects and other related duties as assigned. Make timely decisions on claim approval, partial payment, or denial with clear justifications.

Identify potential fraudulent claims and refer cases as necessary for investigation.

Bachelor’s Degree in Business Administration.Adjusters License from the Office of the Commissioner of Insurance of Puerto Rico (OCS).Demonstrated experience and/or knowledge in claims related to the following coverage’s: Accident, Medical Expenses, Cancer, Critical Illnesses, Disability, Hospitalization, and SINOT, among others including policy interpretation.Strong ability to perform mathematical calculations.Demonstrate flexibility and adaptability to work in a fast moving and challenging environment.Proficient in MS Applications (Word, Excel and Power Point).Intermediate knowledge of the structure and content of the English and Spanish Language.