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Claims Specialist, Sr. Medical Malpractice (Professional Liability)
PRIMARY PURPOSE : To analyze complex or technically difficult medical malpractice claims; to provide resolution of highly complex nature and/or severe injury claims; to coordinate case management within Company standards, industry best practices and specific client service requirements; and to manage the total claim costs while providing high levels of customer service.

EDUCATION & LICENSING

Bachelor’s degree from an accredited college or university preferred. Licenses as required. Professional certification as applicable to line of business preferred.

EXPERIENCE

Six (6) years of claims management experience or equivalent combination of education and experience required.

SKILLS & KNOWLEDGE

• Performs other duties as assigned.
• Supports the organization’s quality program(s).
• In-depth knowledge of appropriate medical malpractice insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security application procedures as applicable to line-of-business
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products<
• Analytical and interpretive skills
• Strong organizational skills
• Excellent negotiation skills
• Good interpersonal skills
• Ability to work in a team environmentAbility to meet or exceed Performance Competencies

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Analyzes and processes complex or technically difficult medical malpractice claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
• Conducts or assigns full investigation and provides report of investigation pertaining to new events, claims and legal actions
• Negotiates claim settlement up to designated authority level.
• Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout claim life.
• Recommends settlement strategies; brings structured settlement proposals as necessary to maximize settlement.
• Coordinates legal defense by assigning attorney, coordinating support for investigation, and reviewing attorney invoices; monitors counsel for compliance with client guidelines. Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall claim cost for our clients.
• Identifies and investigates for possible fraud, subrogation, contribution, recovery, and case management opportunities to reduce total claim cost.
• Represents Company in depositions, mediations, and trial monitoring as needed.
• Communicates claim activity and processing with the client; maintains professional client relationships.
• Ensures claim files are properly documented and claims coding is correct.
• Refers cases as appropriate to supervisor and management.
• Delegates work and mentors assigned staff.