Claim Specialist – Michigan PIP

Position Summary

As a Claim Specialist, you will evaluate coverage, assess claim exposures, and make informed decisions that drive fair and timely resolutions. Working closely with members, medical providers, attorneys, and internal partners under minimal supervision, you'll manage challenging and complex claim scenarios while ensuring compliance with applicable regulations and company standards.

Key Responsibilities

• Review assigned claims and initiate claim handling activities.
• Contact insureds and other affected parties to gather information and set expectations for the claims process.
• Document claim activity and maintain accurate records within the claims management system.
• Perform complex coverage analysis and identify all applicable policyholder benefits.
• Establish and manage sub-claims as needed.
• Conduct thorough investigations to determine coverage applicability, claim validity, policy limits, exclusions, and recovery opportunities.
• Analyze claim facts, damages, state laws, and other relevant factors impacting claim decisions.
• Evaluate the financial value of losses and authorize appropriate claim payments.
• Negotiate settlements and claim resolutions using strong negotiation skills.
• Refer claims to specialized departments when necessary, including Underwriting, Recovery Units, and the Claims Special Investigation Unit (SIU).
• Ensure complete and accurate claim documentation, coding, closure activities, and compliance with company procedures.
• Handle intermediate to complex Michigan Personal Injury Protection (PIP) claims, including: Fractures, Mild closed head injuries, Surgical procedures, Attendant care claims.
• Manage claims involving the Michigan Catastrophic Claims Association (MCCA).
• Handle attorney-represented claims and effectively navigate legal involvement throughout the claim process.
• Investigate and manage losses that may extend beyond standard PIP claim scenarios.
• Collaborate with insureds, physician offices, medical providers, and insurance carriers to obtain necessary documentation and information.
• Review medical and claim-related information to make accurate coverage and payment determinations.
• Maintain compliance with applicable state regulations, company policies, and claim handling standards.

Qualifications

• Required Education: Complete ACG Claim Representative Training Program or demonstrate equivalent knowledge or experience.
• Licenses/Certifications: In states where an Adjuster’s license is required, the candidate must be eligible to acquire a State Adjuster’s license within 90 days of hire and maintain as specified for appropriate states.
• Experience: Three years of experience or equivalent training in the following: Negotiation of claim settlements, Securing and evaluating evidence, Preparing manual and electronic estimates, Subrogation claims, Resolving coverage questions, Taking statements, Establishing clear evaluation and resolution plans for claims.
• Knowledge: Advanced knowledge of: Essential Insurance Act (Michigan), Fair Trade Practices Act as it relates to claims, Subrogation procedures and processes, Intercompany arbitration, Handling simple litigation, Negligence Law, No-Fault Law, medical terminology and human anatomy, MCCA and attorney represented claims.

Skills

• Handle claims to the line
• Claim Handling Standards
• Follow and apply ACG Claim policies, procedures and guidelines
• Work within assigned ACG Claim systems including basic PC software
• Perform basic claim file review and investigations
• Demonstrate effective communication skills (verbal and written)
• Demonstrate customer service skills by building and maintaining relationships with insureds/claimants while exhibiting understanding of their problems and responding to questions and concerns
• Analyze and solve problems while demonstrating sound decision making skills
• Prioritize claim related functions
• Process time sensitive data and information from multiple sources
• Manage time, organize and plan work load and responsibilities
• Safely operate a motor vehicle in order to visit repair facilities, homes (for inspections), patients, etc.
• Research analyze and interpret subrogation laws in various states
• Travel outside of assigned territory which may involve overnight stay
• Work evenings or weekends

Compensation & Benefits Overview

A Claim Specialist earns a competitive annual salary of $67,300-$75,000, along with the opportunity for an annual company bonus incentive. Benefits include: Medical plans with multiple coverage options, including HSA eligibility. Prescription drug coverage. Dental and vision benefits. Employee Assistance Program (confidential support services). Financial Protection & Insurance Company-paid basic life insurance. Optional supplemental life insurance and dependent coverage. Short-term and long-term disability coverage. Critical illness, accident, and pet insurance options. Retirement & Savings 401(k) plan to support long-term financial goals. 3% automatic deferral upon eligibility; may contribute 1% to 50% of eligible earnings, either pre or post tax. Company match of 50% paid on employee contributions up to 6% of pay, payable to employees following the end of the year; immediate vesting. Additional company contribution of 4% of pay each pay day into your account; 100% vested after three (3) years of service. Health Savings Account (HSA) and Flexible Spending Accounts (FSA) options. Time Off & Leave Paid Time Off (PTO): Accrual-based, increases with tenure, eligible at 90 days of employment. Full-time new employees will receive up to 12 PTO days annually; accrual based on start date and may include additional PTO based on role and/or state & local requirements. Part-time employee PTO hours are calculated based upon the standard weekly hours the employee is scheduled to work and will accrue at a minimum of 3 hours per month. Paid Holidays: Full-time employees are eligible for 10 company-paid holidays annually, in addition to 1 mental health day, 2 floating holidays and 1 volunteer day. Holidays vary by business unit schedules. Part-time employees are eligible for 8 company-paid holidays annually, in addition to 1 mental health day and 2 floating holidays. Holidays vary by business unit schedules. Paid leave programs, including parental, bereavement, jury duty, and military leave. Career Growth & Education Tuition assistance (up to $5,250 annually; 80% covered by ACG). Professional certification support with 100% reimbursement for eligible programs. Opportunities for career development and advancement. Additional Perks Complimentary AAA membership with roadside assistance and travel discounts. Adoption assistance program.