Claims Specialist - Executive Claims Specialist - Allied Health Claims

Job Summary

Under minimal supervision, the Claims Specialist/Executive Claims Specialist manages a caseload of high complexity commercial insurance claims focused on Allied Health (assisted living and skilled nursing facilities). The Claims Specialist will review claims to analyze land determine applicable coverage, facts, liability, damages, plan and strategy for resolution in accordance with state and company guidelines. The Claims Specialist will function independently and act as a key resource on issues within area of specialty.

Duties and Responsibilities

• Continuously exhibit and uphold Core Values of Integrity, Accountability, Communication and Teamwork, Innovation and Customer Service
• Perform coverage, liability, and damage analysis on all claims assignments
• Investigate allegations, determine facts based on evidence and interviews
• Draft disclaimers and reservation of rights letters when coverage issues arise
• Assign limited investigations and appraisals to independent licensed professionals
• Manage a caseload of high complexity claims with delegated authority
• Manage litigated files
• Negotiate settlements, mitigate losses, and control expenses
• Participate in and attend mediations to facilitate settlements
• Maintain accurate documentation in claim files
• Maintain a high level of communication internally with Claims management team and externally with insureds, claimants, attorneys and brokers
• Act as a consultant providing technical expertise within specialty area to internal stakeholders
• Provide technical guidance, assistance and training as needed for less experienced Claims professionals
• Maintain a passing quality assurance score on all audits and QAs
• Provide exceptional customer service to insureds, claimants, and attorneys, addressing inquiries, concerns, and providing regular updates on claim status
• Ensure compliance with state regulations, industry standards, and best practices in claims handling, maintaining a high level of professionalism and integrity
• Handle claims in accordance with established James River Claims Best Practices
• Other duties as required by management

Knowledge, Skills and Abilities

• Extensive expertise in specific specialty area of claims (i.e. PL, M&C, GL)
• Expert level of expertise in claim handling and suit management
• Expert knowledge of P&C insurance industry
• Expert ability to effectively assess risk
• Proficiency in MS Office (Word, Excel, Outlook)
• Excellent written and verbal communication skills
• Advanced analytical and organizational skills
• Advanced negotiation skills
• Ability to work independently and take initiative
• Ability to exercise sound judgement in making critical decisions
• Research, analysis and problem-solving skills
• Ability to work in a team environment and accept feedback from Claims management
• Ability to build effective relationships with business partners
• Ability to organize complex information and pay close attention to detail
• Ability to anticipate customer needs and take initiative to meet those needs
• Ability to train and provide technical guidance to less experienced Claims professionals
• Ability to successfully obtain the required state adjusters' licenses within six (6) months following the completion of Company-provided licensure training courses and maintain appropriate licensure thereafter

Experience and Education

Claims Specialist

• High school diploma required
• Bachelor's Degree preferred
• Advanced Degree or Juris Doctorate Degree preferred
• Minimum of seven years of experience handling primary and excess claims-made and occurrence liability policies and claims.
• Experienced in coverage, liability, and litigated claims related to health services claims, assisted living and skilled care facilities claims, life sciences (medical devices and products) claims, and professional liability claims.
• Successful candidate will have strong written, verbal, injury evaluation, and negotiation skills
• Adjuster license and/or certifications desired preferred

Executive Claims Specialist

• High school diploma required
• Bachelor's Degree preferred
• Advanced Degree or Juris Doctorate Degree preferred
• Minimum of ten years of experience handling primary and excess claims-made and occurrence liability policies and claims.
• Experienced in coverage, liability, and litigated claims related to health services claims, assisted living and skilled care facilities claims, life sciences (medical devices and products) claims, and professional liability claims.
• Successful candidate will have strong written, verbal, injury evaluation, and negotiation skills
• Extensive expertise in specific specialty area of claims (i.e. PL, M&C, GL)
• Project management and process implementation experience preferred

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Please note that this position is not eligible for H-1B visa sponsorship. All applicants must be currently authorized to work in the United States on a full-time basis without the need for current or future H-1B sponsorship.