Sr. Claims Specialist - Medical Malpractice (LTC)

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Sr. Claims Specialist, Medical Malpractice (LTC)

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.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Analyze 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.

​QUALIFICATION

• Performs other duties as assigned.

• Supports the organization's quality program(s).

Experience

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

Skills & Knowledge

• 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

• When applicable and appropriate, consideration will be given to reasonable accommodations.

Education & Licensing

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

WORK ENVIRONMENT

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

NOTE: Credit security clearance, confirmed via a background credit check, is required for this position.  

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $100,000. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description.  They are not intended to constitute a comprehensive list of functions, duties, or local variances.  Management retains the discretion to add or to change the duties of the position at any time.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.