Complex Claims Consultant

4 weeks ago

Glastonbury, United States CNA Full time

JOB DESCRIPTION

:

Essential Duties & Responsibilities

Performs a combination of duties in accordance with departmental guidelines:

Manages an inventory of highly complex healthcare professional liability claims, with large exposures that require a high degree of specialized technical expertise and coordination, by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits. Ensures exceptional customer service by managing all aspects of the claim, interacting professionally and effectively, achieving quality and cycle time standards, providing timely updates and responding promptly to inquiries and requests for information.  Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language, estimating potential claim valuation, working with counsel and following the company's claim handling protocols. Leads focused investigation to determine compensability, liability and covered damages by gathering pertinent information, such as contracts or other documents, taking recorded statements from customers, claimants, witnesses, and working with experts, or other parties, as necessary to verify the facts of the claim. Resolves claims by collaborating with internal and external business partners to develop, own and execute a claim resolution strategy, that includes management of timely and adequate reserves, collaborating with coverage experts where necessary, negotiating complex settlements, partnering with counsel to manage complex litigation and authorizing payments within scope of authority. Establishes and manages claim budgets by achieving timely claim resolution, selecting and actively overseeing appropriate resources, authorizing expense payments and delivering high quality service in an efficient manner. Realizes and addresses subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Claim, Recovery or SIU resources for further investigation. Achieves quality standards by appropriately managing each claim to ensure that all company protocols are followed, work is accurate and timely, all files are properly documented and claims are resolved and paid timely.  Keeps leadership informed of significant risks and losses by completing loss summaries, identifying claims to include on oversight/watch lists, and preparing and presenting succinct summaries to senior management. Maintains subject matter expertise and ensures compliance with state/local regulatory requirements by following company guidelines, and staying current on commercial insurance laws, regulations or trends for line of business. Mentors, guides, develops and delivers training to less experienced Claim Professionals.

May perform additional duties as assigned.

Reporting Relationship

Typically Director or above
 
Skills, Knowledge & Abilities

Thorough knowledge of the professional liability insurance industry, products, policy language, coverage, and claim practices. Strong communication and presentation skills both verbal and written, including the ability to communicate business and technical information clearly. Demonstrated analytical and investigative mindset with critical thinking skills and ability to make sound business decisions, and to effectively evaluate and resolve ambiguous, complex and challenging business problems. Strong work ethic, with demonstrated time management and organizational skills. Ability to work in a fast-paced environment at high levels of productivity. Demonstrated ability to negotiate complex settlements. Experience interpreting complex insurance policies and coverage.  Ability to manage multiple and shifting priorities in a fast-paced and challenging environment. Knowledge of Microsoft Office Suite and ability to learn business-related software. A commitment to collaboration and demonstrated ability to value diverse opinions and ideas.

Education & Experience:

Bachelor's Degree or equivalent experience. JD a plus. Typically a minimum six years of relevant experience, preferably in claim handling or medical malpractice litigation. Candidates who have successfully completed the CNA Claim Training Program may be considered after 2 years of claim handling experience. Must have or be able to obtain and maintain an Insurance Adjuster License within 90 days of hire, where applicable. Professional designations are a plus (e.g. CPCU).

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