Senior Claims Specialist (Healthcare)

This position in Healthcare Claims will be responsible for the resolution of moderate to high complexity and moderate to high exposure claims which can be subject to disputes that must be resolved in mediation or litigation. The primary purpose of this job is to handle claims in the excess and reinsurance categories: from coverage enquiry through legal liability assessment (where relevant) and quantum analysis, to timely and accurate resolution; ensuring mitigation of indemnity and expense exposure while communicating developments and outcomes as necessary to all internal and external stakeholders. The position will have increased responsibility for decision making within their authority and work with minimal oversight and will provide training and be a technical referral point for other team members. College degree is required and a JD and/or minimum of 5 years claims handling experience is preferred.

Job Responsibilities

• Confirms coverage of claims by reviewing policies and documents submitted in support of claims
• Directs and monitors assignments to experts and outside counsel, ensures effective vendor and litigation management on moderate to high complexity claims including demonstrable savings
• Analyzes coverage and communicates coverage positions
• Prepare coverage position letters on matters typically in litigation without assistance of outside coverage counsel.
• Utilizes acceptable investigation claims handling and settlement techniques that achieve cost effective and timely closure results by obtaining, reviewing and analyzing documentation, policy provisions and other records.
• Conducts, coordinates, and directs investigation into loss facts and extent of damages
• Provides timely service throughout the life cycle of the claim by meeting all service level agreements, initiating timely contact to all appropriate parties, and responding to incoming inquiries according to company policy and procedures.
• Evaluates information on coverage, liability, and damages to determine the extent of insured's exposure
• Sets reserves within authority or makes claim recommendations concerning reserve changes to manager
• Negotiates and settles claims typically in litigation either directly or indirectly
• Prepares reports by collecting and summarizing information
• Present at roundtables to senior claims leaders and underwriters on cases going to trial
• Participates in special projects or assists other team members as requested
• Travel to mediations, trials, and conferences as required
• Coordinates loss information for business stakeholders and presents information during meetings with underwriters and/or insureds when applicable
• Contributes to maintenance of claims guidelines and best practice procedures
• Delivers technical training to colleagues and external contacts as appropriate

Education

• Bachelor’s degree or equivalent work experience
• JD , advanced degree, or focused technical degree a plus

Certification

• Must have or be eligible to receive claims adjuster license.
• Successful achievement of industry designations (INS, IEA, AIC, ARM, SCLA, CPCU) or
• Participation in industry training opportunities (CLM Claim College, Munich Re Training, FDCC, etc.)

Work Experience

• Minimum of 7-15 years of claims handling experience or equivalent combination of education and experience in insurance
• Successful completion of 5 years as a Claims Examiner

Skill Sets

• Excellent written and oral communication skills
• Strong analytical and problem solving skills
• Strong organization and time management skills
• Experience in negotiation, mediations, arbitrations and monitoring trials on higher value complex claims
• Ability to influence claims stakeholders and to effectively direct claims strategy
• Strong vendor management skills are required including the ability to provide direction and guidance to defense attorneys, independent adjusters, building consultants, forensic accountants and other experts while controlling expenses.
• Ability to assist with technical training to team claim handlers as required
• Well developed and advanced expertise and knowledge in most technically complex claims topics
• Policy language skills enabling accurate and consistent policy wording interpretation
• Experience in effectively following up on recommendations from technical claims audits and continuous file handling improvement.
• Ability to deliver outstanding customer service
• Intermediate skills in Microsoft Office products (Excel, Outlook, Power Point, Word)
• Ability to work in a team environment
• Strong desire for continuous improvement