STD Claims Examiner II making accurate claim decisions for Short Term Disability claims. Collaborating with team members in a hybrid work environment from South Portland, ME.
About the role
- Claims Specialist managing various insurance claims for Caradoc Townsend Mutual Insurance Company. Investigating, evaluating, and resolving claims while ensuring compliance and quality assurance.
Responsibilities
- Investigate and evaluate claims across multiple lines of business (property, auto, and liability) to determine coverage, liability, damages, and appropriate settlement outcomes.
- Review claim documentation, policy wording, endorsements, and supporting evidence to confirm eligibility and compliance.
- Communicate with claimants, insureds, witnesses, brokers, and third parties to gather required information and explain claims processes and decisions.
- Negotiate settlements in accordance with policy provisions and delegated authority.
- Identify claims requiring escalation, litigation, or external expertise and provide recommendations to management and legal counsel.
- Participate in litigation support activities, including file preparation, consultations with counsel, and attendance at hearings where required.
- Handle Property, Liability, Accident Benefits and Bodily Injury claims as required, with focus on Accident Benefits claims, in support of overall multiline adjusting needs.
- Provide technical guidance and interpretation of policy coverage, exclusions, and conditions to ensure consistent claims handling.
- Review and analyze complex or escalated claims files to ensure adherence to internal standards, regulatory requirements, and best practices.
- Support consistency in reserving practices and submit claim liability information to actuarial or leadership teams as required.
- Assist in resolving claims-related complaints and appeals requiring advanced technical review.
- Act as a resource for staff on coverage interpretation and adjusting practices, including property, auto, and liability claims.
- Review claims processes, procedures, and workflows to identify opportunities for efficiency, accuracy, and quality improvement.
- Ensure claims handling aligns with company policies, procedures, and applicable legislation and regulatory standards.
- Prepare reports and analyze claims data to support monitoring, quality assurance, and management decision-making.
- Contribute to training initiatives, documentation, and knowledge sharing related to complex claims handling and policy interpretation.
Requirements
- Post-secondary education in insurance, business, or a related field, or an equivalent combination of education and experience.
- Minimum 5–7 years of progressive experience in multiline insurance claims, preferably within a mutual insurance environment.
- Strong technical knowledge of insurance policy wording, coverage analysis, liability determination, and claims reserving.
- Experience handling complex, high-value, or escalated claims and supporting litigation-related activities.
- Familiarity with Ontario insurance legislation, regulatory requirements, and industry best practices.
- Knowledge of Ontario insurance legislation across multiple lines of business, including Property, Auto, Liability, and Accident Benefits.
- Professional insurance designation (e.g., CIP, FCIP, or working toward) is strongly preferred.
- Excellent analytical, communication, and negotiation skills.
- Strong attention to detail and ability to exercise sound judgment in complex situations.
Benefits
- Health insurance
- Flexible work arrangements
- Professional development opportunities
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