Complex Claims Consultant - Hospitals , Allied Facilities and Physicians

Job Summary

Required Qualifications

• •Bachelor's Degree
• •Equivalent experience
• •Typically a minimum six years of relevant experience
• •Experience in claim handling
• •Must have or be able to obtain and maintain an Insurance Adjuster License within 90 days of hire, where applicable
• •Prior negotiation experience
• •Thorough knowledge of the commercial insurance industry
• •Knowledge of commercial insurance products
• •Knowledge of policy language
• •Knowledge of coverage
• •Knowledge of claim practices
• •Strong communication and presentation skills
• •Verbal communication skills
• •Written communication skills
• •Ability to communicate business and technical information clearly
• •Analytical and investigative mindset
• •Critical thinking skills
• •Ability to make sound business decisions
• •Ability to effectively evaluate and resolve ambiguous, complex and challenging business problems
• •Strong work ethic
• •Time management skills
• •Organizational skills
• •Ability to work in a fast-paced environment
• •Ability to work at high levels of productivity
• •Demonstrated ability to negotiate complex settlements
• •Experience interpreting complex commercial insurance policies
• •Experience interpreting complex commercial insurance coverage
• •Ability to manage multiple and shifting priorities
• •Ability to work in a fast-paced and challenging environment
• •Knowledge of Microsoft Office Suite
• •Ability to learn business-related software
• •Ability to value diverse opinions and ideas
• •Innovative and adaptive to evolving Claims environment
• •Ability to incorporate the use of AI as appropriate with handling claims
• •Subject matter expertise
• •Ability to ensure compliance with state/local regulatory requirements
• •Ability to follow company guidelines
• •Ability to stay current on commercial insurance laws, regulations or trends for line of business
• •Ability to mentor, guide, develop and deliver training to less experienced Claim Professionals
• •Ability to coordinate all claim resolution activities in accordance with company protocols
• •Ability to achieve quality and customer service standards
• •Ability to communicate with customers and insureds
• •Ability to manage complex hospitals, allied facilities and physicians claims
• •Ability to manage claims with high complexity and exposure
• •Ability to verify policy coverage
• •Ability to conduct investigations
• •Ability to develop and employ resolution strategies
• •Ability to authorize disbursements within authority limits
• •Ability to manage all aspects of the claim
• •Ability to interact professionally and effectively
• •Ability to achieve quality and cycle time standards
• •Ability to provide timely updates
• •Ability to respond promptly to inquiries and requests for information
• •Ability to review and interpret policy language
• •Ability to partner with coverage counsel on more complex matters
• •Ability to estimate potential claim valuation
• •Ability to follow company's claim handling protocols
• •Ability to lead focused investigation
• •Ability to determine compensability
• •Ability to determine liability
• •Ability to determine covered damages
• •Ability to gather pertinent information
• •Ability to take recorded statements from customers, claimants, injured workers, witnesses, and other parties
• •Ability to work with experts or other parties
• •Ability to verify the facts of the claim
• •Ability to resolve claims
• •Ability to collaborate with internal and external business partners
• •Ability to develop, own and execute a claim resolution strategy
• •Ability to manage timely and adequate reserves
• •Ability to collaborate with coverage experts
• •Ability to negotiate complex settlements
• •Ability to partner with counsel to manage complex litigation
• •Ability to authorize payments within scope of authority
• •Ability to establish and manage claim budgets
• •Ability to achieve timely claim resolution
• •Ability to select and actively oversee appropriate resources
• •Ability to authorize expense payments
• •Ability to deliver high quality service in an efficient manner
• •Ability to realize and address subrogation/salvage opportunities or potential fraud occurrences
• •Ability to evaluate the facts of the claim
• •Ability to make referrals to appropriate Claim, Recovery or SIU resources
• •Ability to ensure that all company protocols are followed
• •Ability to ensure work is accurate and timely
• •Ability to ensure all files are properly documented
• •Ability to ensure claims are resolved and paid timely
• •Ability to keep senior leadership informed of significant risks and losses
• •Ability to complete loss summaries
• •Ability to identify claims to include on oversight/watch lists
• •Ability to prepare and present succinct summaries to senior management
• •Ability to maintain subject matter expertise
• •Ability to ensure compliance with state/local regulatory requirements
• •Ability to stay current on commercial insurance laws, regulations or trends for line of business

Desired Qualifications

• •Professional designations
• •e.g. CPCU