Complex Loss Specialist

Role Description

The Complex Loss Specialist position at Golden State Claims Services reports to a Claims Supervisor or Claims Manager and will specialize in Allied Health claims. The chief duty of the Complex Loss Specialist for Allied Health claims is to adjust the most time-intensive, complex, and high exposure losses that require a higher level of technical expertise, knowledge, and negotiating ability.

• Provide analysis and presentations to Senior Executives and Program Executives for complex matters.
• Lead strategic roundtable discussions to determine optimal resolution strategy.

Qualifications

• Minimum of 10 years of claims experience, with an emphasis on complex Allied Health claims.
• College degree or equivalent claims management experience required.
• Minimum of 10 years litigation management experience preferred.
• Must hold an individual adjusting license for a designated home State and be willing to secure additional required adjusting licenses as needed.
• Active adjusters license under your name required.
• Proficient computer skills including Microsoft Outlook, Word, and Excel.
• Ability to maintain consistent and clear communication with leadership, the team, and all other external points of contact.

Requirements

• Contribute to a collaborative environment by demonstrating teamwork, high motivation, positive behavior, and effort to achieve goals and objectives.
• Build and maintain productive relationships with internal and external customers, including clients, underwriting and service teams, and agents.
• Research applicable coverage for insureds and document coverage dates, limits, and restrictions.
• Identify and resolve potential coverage questions; draft reservation of rights and coverage denials for review and approval.
• Investigate facts of the loss by securing statements and supporting documentation.
• Document activities in writing within claim files.
• Exercise judgment in applying legal liability to assigned claims and have settlement authority.
• Assign defense counsel to answer and defend lawsuits where appropriate.
• Monitor and direct defense counsel, independent adjusters, and experts.
• Identify claims with potential exposure in excess of authority and advise Supervisor/Manager.
• Evaluate, set, or recommend reserves for each file handled.
• Prepare written reports as dictated by company policy and procedures.
• Handle claims within guidelines of the Fair Claims Practices 790.03.
• Provide insureds, claimants, underwriters, and carriers with regular updates on status of file handling.
• Discuss unique and complex files with Supervisor/Manager.

Core Technical Duties

• Healthcare liability claims investigation and evaluation, including medical malpractice, general liability, and professional liability exposures.
• Coverage analysis and interpretation of allied health professional liability policies.
• Medical record review and interpretation across allied health disciplines.
• Drafting reservation of rights letters and coverage denial communications for supervisor review.
• Reserve evaluation, setting, and recommendation based on exposure analysis and claim trajectory.
• Litigation management, including assignment and direction of defense counsel, independent medical examiners, and expert witnesses.

Benefits

• Employee Ownership Program - every eligible employee shares in the financial rewards that grow when the company grows.
• Professional development opportunities.
• Owner Referral Program.
• Work from home reimbursement for remote/hybrid roles.
• Canary emergency financial assistance program.
• Comprehensive medical, dental, vision.
• Life/AD&D Insurance.
• Confidential, Employee Assistance Program.
• Health Savings Account, includes company contribution.
• Short-term disability.
• Voluntary benefits - supplemental accident, critical illness, hospital insurance.
• Employee discounts.
• 401(k) Plan with company match contribution.
• Addition Wealth Financial Wellness Program.
• Various Time Off Programs.
• 11 company paid holidays.