JOB PROFILE CLAIMS ADJUSTER

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1 JOB PROFILE CLAIMS ADJUSTER OVERVIEW It s about you What is claims adjustment? What is the role of (job)? Do you enjoy working relatively independently in a fast faced environment? Do you like a varied work environment at times working in an office while at other times being in the field assessing situations and managing client claims? Are you able to deal with fluctuations in workload, willing to work irregular hours and be on call? Do you enjoy being actively involved in negotiations to settle claims? If so, Claims Adjuster may the right role for you. Claims adjustment involves investigating insurance claims and reconciling them against policy provisions to determine the degree of the organization s liability. Claims Adjusters are primarily responsible for the review of claims for a specific type of insurance claim (i.e., life, property, accident-benefit); this includes gathering information required to substantiate claims, reconciling the claim against policy provisions and either approving payment or escalate the claim by providing a report to claims examiners/processers. 1 P age

2 OVERVIEW, CONTINUED Work context for this role Areas of focus Claims Adjusters typically work in a fast-paced environment to process high volumes of claims in a timely manner. There is significant pressure to meet strict deadlines for claimants/clients and work load is based upon the fluctuation in claims. In the case of natural disasters, or severe weather events, claims can increase suddenly. Claims Adjusters typically have some experience in the insurance field and more senior Claims Adjusters will deal with more complex policies and claims with increasing face value / liability. In addition, senior Claims Adjusters will have more in-depth technical knowledge of their line of insurance (e.g., property and casualty, health insurance) and may be enabled to negotiate settlements within defined limits. Claims Adjusters need to be mobile and physically able to investigate the scene. They may be on call 365 days per year, 24 hours per day. There are times when adjusters need to be in the field to assess situations and manage claims such as when there is damage to a home or vehicle, while at other times adjusters can remain in the office accepting basic claims at face value such as health claims that come through a group benefits plan. Some organizations may enable their Claims Adjusters to work in the field thereby working on a very mobile basis. Many Claim Adjusters receive assignments via /website and are required to complete work independently and track work related expenses. There are two types of Claims Adjusters: Employees of insurance companies Independent adjusters who are typically hired by smaller underwriters who outsource claims work Claims Adjusters typically work in insurance organizations and focus on developing expertise within a particular line of insurance (i.e., life, accident-benefit, property, commercial, specialized in factories, warehouses, etc.) 2 P age

3 QUALIFICATIONS Qualifications for this role Knowledge requirements: Claims Adjusters require specific knowledge of: Technical Skills: Policy coverage, limits of liability & reinsurance policies Investigation procedures and documentation, this may include consulting police and hospital records, and reviewing property damage Technical & financial terms which may include understanding of valuation of depreciated assets in the case of property claims and replacement cash valuations The line of business and supporting knowledge for that line. For example, an auto mechanic may make an effective adjuster because he/she may have a sense of the true value of the loss related to damage to an automobile and be able to estimate repair costs Legislation around liability that exists within the criminal code and any violations may impact the outcome of the claim and how it is processed (e.g., blood/alcohol limits, changes to clean air legislation for motor vehicles) Privacy legislation as adjusters need to be aware of what they are allowed to divulge and what is considered private under the legislation Claims Adjusters require specific technical skills: Soft Skills: Computer skills (e.g., proficiency in MS Office applications, spreadsheet proficiency, the systems and software the organization uses) Media recording skills (e.g., digital camera, audio/visual recording devices) Time management and prioritization skills to effectively manage case load Claims Adjusters require specific soft skills: Analytical skills to assess the damage and situation Communications Skills (written and verbal) to communicate with the client and others as appropriate about the claim Detail orientation to complete all required documentation appropriately and understand any necessary details of the policy Information seeking to conduct any required research and review information pertaining to the claim Personal organizational skills to maintain the workflow of paper documentation required Problem solving to determine how to resolve issues and deal with the claim effectively Applicable Experience: Applicable experience generally includes a role or education with exposure to claims (i.e., Claims Assistant or other junior insurance role). 3 P age

4 QUALIFICATIONS, CONTINUED Qualifications for this role, continued Education, Certifications, Designations and Licenses: Positions typically require post-secondary education; business degrees are often preferred or a degree for a related field in the type of insurance. For example: Engineering and architectural backgrounds for property/industrial claims, Health Sciences such as biology or kinesiology for health or personal injury related claims, or chemistry for fire causation General Arts in psychology or criminology Skill trade such as automotive or construction There are 8 colleges/universities that offer students the opportunity to earn Chartered Insurance Professional credits while completing their diploma: British Columbia Institute of Technology (BCIT) Grant MacEwan University Mount Royal University Saskatchewan Institute of Applied Science and Technology (SIAST) Conestoga College Fanshawe College Mohawk College Seneca College There are 3 universities with an Insurance Chair and full time study options in Insurance & Risk Management: Wilfrid Laurier University Universite Laval University of Calgary There are many other schools that offer continuing education/part-time learning options focused on insurance across the country: Note: More information about insurance education and these programs can be found on our web site at Programs/Canadian-University-College-Programs/Canadian-University-College- Programs.aspx In the case of property Claims Adjusters, physical mobility is also required as there may be physical demands to properly investigate damaged property. 4 P age

5 QUALIFICATIONS, CONTINUED Qualifications for this role, continued Other Training: Additional certifications may include: Independent adjusters require an adjuster s license which can be obtained by completing the first four credits of the Chartered Insurance Professional (CIP) designation. C11 The Principles and Practices of Insurance is completed. C12 Insurance of Property C14 Automobile Insurance Part 1 C110 Essentials of Loss Adjusting Professional Associations may include: CIP Membership 5 P age

6 DUTIES Main duties The main duties of the Claims Adjuster: Collect information required to substantiate claims Key activities: Meet with clients, discuss claims and identify needs Gather the necessary information by conducting field inspections where required, interview appropriate parties (e.g., law enforcement, lawyers, consultants, witnesses), and reviewing any available information/reports (e.g., police reports, court reports; medical records) Assess true value of the loss Maintain relationships with attorneys, claimants and subject matter experts Key activities: Remain in contact on a regular basis and provide /obtaini status updates regarding claim Discuss needs, concerns and respond to requests in a timely manner Be fair and honest in all transactions, seek what is right and be respectful of others Reconcile claims against policy provisions Key activities: Review details regarding claim - Review policy in detail to determine what is covered Make recommendations/approve/adjust payment of benefits based on policy Provide written reports to re-insurers/excess carriers when required Note: - Reinsurance is insurance purchased by insurers from other insurers to limit the total loss an insurer would experience in case of a disaster. For example, Company A may underwrite $5,000,000 in a policy but they reinsure 60% of all risk, so, in the event of a maximum claim they must pay $2,000,000 but the reinsurer is then responsible for paying $3,000,000 - Excess carriers are when there is a limit to liability on a primary policy and the insured has an excess policy, with another insurance firm, to increase that limit. For example, if an insured wants a $3,000,000 life insurance policy, but Company A will provide a maximum of $2,000,000 coverage only. Then, the insured may have an excess policy with Company B for $1,000,000 to enable themselves to have their desired coverage level. 6 P age

7 CAREER PATH Moving into the role Progression beyond the role To move into a Claims Adjuster role, you need to have a post-secondary education and/or experience in a field relevant to the line of insurance for which the adjuster will provide expertise. As you gain experience in the Claims Adjuster role, you may take on additional supervisory and management duties or become a more senior Claims Adjuster. CAREER IMPACTS External environmental factors impacting the role Career Outlook Compensation There are several external factors that can influence the qualifications for the role, including: Type of claims (line of business) will have a varying level of expertise required Legislation and regulatory requirements World events such as the nuclear disaster in Japan, hurricanes and tornadoes, as adjusters are often ask to assist with these situations There is substantial opportunity and anticipated growth for this role into the future. Claims Adjuster is one of the roles included on the list of 29 in-demand jobs in Canada created by the Canadian Government. If the Claims Adjuster is employed by an organization then this position may consist of a total compensation package that includes base salary and a car or mileage reimbursement. Independent Claims Adjusters bill their time on an hourly basis and can work as often or as little as they want. 7 P age