Claims Representative

Professional Liability Claims Investigator

Responsible for the investigation, evaluation, negotiation, and resolution of professional liability claims involving insured health care providers and facilities. This role manages claims from initial notice of claim through final disposition, ensuring timely, fair, and cost-effective outcomes while complying with applicable laws, regulations, and company policies.

Essential Functions:

Answering phone calls in the claims phone queues, including risk management questions and claim reporting intake, and documenting all phone calls in detailed claim or policy notes.

Handling professional liability claims and administrative claims such as licensing board proceedings and insurance audits, including claim intake, coverage verification, claim opening, assigning counsel, retaining expert consultants, review of medical records, investigating, evaluating, providing directives and communicating with defense counsel, and negotiating settlements within provided settlement authority.

Drafting claim letters, including detailed reservation of rights letters, coverage denial letters citing specific policy language, basic claim opening and closing letters.

Completing financial transactions, including settlement payments with NPDB reporting, paying defense and expert bills both manually and via Datalytics, completing check voids.

Attending court-ordered appearances and mediations, either virtually or in-person as required.

Other duties as assigned.

Requirements:

College degree with insurance certifications such as AIC, SCLA, and CPCU preferred. Valid applicable adjuster licensure or ability to become licensed within 90 days.

3-5 years claims-handling experience, with emphasis on professional liability claims preferred.

Excellent time management and ability to prioritize pending work based on urgency. Excellent negotiating skills, verbal and written communication skills, listening and reading comprehension, attention to detail. Ability to read and interpret insurance policy language, apply it to various claim scenarios, and effectively communicate coverage decisions. Knowledge of medical and legal terminologies and concepts.

Mental Demands:

Ability to focus on tasks for extended periods of time. Flexible and able to work with a variety of tasks and colleagues. Ability to plan, organize, be detail and deadline oriented, and maintain high accuracy. Able to maintain professional communications when discussing sensitive topics, questions, or claims situations. Able to interpret data and problem solve to make effective and efficient decisions independently or collaboratively.

Physical Demands:

Continuous sitting, some standing, walking, bending and reaching. Frequent use of fingers and hands to manipulate computer, telephone, and other office equipment. Ability to travel by car or plane if necessary.