Complex Claims Specialist: Misc. Medical Facilitates/Long Term Care

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Are you looking to use your customer service skills in a role where you can see that you are making a difference in people's lives? Do you want a career with endless opportunities for growth?

With minimal supervision, the Complex Claims Specialist will handle Healthcare Miscellaneous Medical Facilities claims, throughout the entire claim's life cycle. Responsible for evaluating coverage, issuing coverage determination letters, conducting investigations, recommending adequate reserves, monitoring, documenting, and settling/closing claims in an expeditious and economical manner within prescribed authority limits for the line of business. Bulk of claim assignments will concern MMF insureds with some Long Term Care, but there may be opportunities to handle medical malpractice claims on other lines of business (HPL, PPL) in the future.

Responsibilities:

• Analyzes, investigates, and evaluates the loss to determine coverage and claim disposition.
• Utilizes CMS to document claims and to diary future events or follow-up.
• Within prescribed settlement authority for line of business, establishes appropriate reserves for both indemnity and expense and reviews on a regular basis to ensure adequacy.
• Makes recommendations to set reserves at appropriate level for claims outside of authority level.
• Prepares comprehensive reports as required.
• Identifies and communicates specific claim trends and account and/or policy issues to management and underwriting.
• Manages the litigation process through the retention of counsel. Adheres to the line of business litigation guidelines to include budget, bill review and payment. Pro-actively manages the case resolution process.
• Actively participates in mediations and arbitrations, within limit of settlement authority. Participates in the claims audit process.
• Provides claims marketing services by meeting with brokers, risk managers and reinsurers, as necessary.
• As required, maintains insurance adjuster licenses.

• Medical Malpractice Claims Experience Preferred
• 7 + years claims experience with at least 2 years within a technical specialty.
• Bachelors' and/or advanced degree.
• Advanced knowledge of claims handling concepts, practices and techniques, to include but not limited to coverage issues, and product line knowledge.
• Functional knowledge of law and insurance regulations in various jurisdictions.
• Demonstrated advanced verbal and written communications skills.
• Demonstrated advanced analytical, decision making and negotiation skills.
• Ability to travel up to 25%