Role Overview
As a Senior Claim Consultant, you will lead the end-to-end management of medical professional liability and general liability claims. Your primary responsibility is to assess liability, oversee investigations, and guide cases toward resolution in alignment with company guidelines and regulatory standards.
Key Responsibilities
- Conduct interviews with insured parties, witnesses, and claimants to gather critical information for evaluating exposure and liability.
- Document findings, negotiations, and case developments thoroughly and on schedule to maintain accurate claim files.
- Prepare and submit regular reports and updates according to established timelines to support effective case planning.
- Obtain medical records, legal documents, and other relevant materials necessary for case evaluation.
- Develop and execute negotiation strategies within delegated authority, securing favorable settlements while managing risk.
- Adjust claim reserves as appropriate and provide recommendations to management for cases exceeding authority limits.
- Assess each claim for optimal resolution and escalate settlement decisions when required.
- Supervise defense counsel activities to ensure adherence to case management protocols.
- Attend mediations, arbitrations, and pre-trial proceedings as needed, and monitor trials when necessary.
- Identify potential underwriting or risk management concerns and communicate them to the appropriate internal teams.
- Engage regularly with insureds, claimants, and legal representatives, adapting investigative methods based on claim type.
- Analyze claims to determine coverage applicability under current policies.
- Maintain up-to-date knowledge of insurance policy forms and verify coverage based on the date of loss.
- Perform additional duties as assigned by leadership.
Required Qualifications
- Bachelor’s degree from an accredited four-year institution.
- Proficiency in medical, legal, and insurance terminology.
- Valid driver’s license must be maintained.
- Strong written and verbal communication skills, including the ability to present information clearly to internal teams and external parties.
- Training in contract and policy analysis and application.
- Ability to interpret insurance policies, technical documents, regulations, and professional journals.
- Skilled in writing detailed reports, correspondence, and case summaries.
- Capable of presenting information and responding to inquiries from managers, attorneys, agents, and insureds.
- Proven ability to synthesize complex data, conduct research, and apply judgment to inform decisions.
- Experience developing workflows and creative problem-solving approaches.
- Proficiency in Microsoft Word, Excel, and PowerPoint.
- Ability to work independently with minimal daily oversight.
- Willingness to travel overnight as needed, up to 25% of the time.
Preferred Qualifications
- Registered Nurse (R.N.) or Juris Doctor (J.D.) with at least five years of clinical nursing experience or five years of claims experience involving serious bodily injury.
- An insurance adjuster’s license may be required depending on state regulations.
