Claims / TPA Oversight General Liability Medical Malpractice

Claims / TPA Oversight General Liability Medical Malpractice

Property and Casualty Insurance Industry

Description:

The suitable applicant will oversee intricate claims related to Senior Care General Liability (GL) and P&L, which encompasses tasks such as investigation, coverage analysis, liability assessment, litigation oversight, and resolution. This position demands significant direct experience in handling claims. Candidates with backgrounds in legal or clinical fields (like nursing) are highly valued alongside proven expertise in claims management. You will be responsible for managing a portfolio of Senior Care GL and P&L claims from the initial notification to resolution independently. This involves conducting comprehensive investigations that include reviewing medical records, analyzing incidents, and evaluating facility documents. You will perform coverage assessments and liability evaluations, documenting your findings in a clear and defensible way. It's essential to identify factors affecting severity, signs of fraud, and potential litigation risks, escalating issues as necessary. You will manage defense attorneys, overseeing budgetary concerns, litigation strategies, and monitoring their performance. Assess claims for possible settlements, prepare requests for authority, and negotiate resolutions within the given authority. Ensure accurate reserves and timely documentation of claim files following internal guidelines. Work together with internal partners, nurse reviewers, and legal counsel to achieve successful claim outcomes.

Requirements :

Over five years of experience in managing liability claims directly, showcasing responsibility for claims from initiation to final resolution. A solid track record in handling litigated claims, which includes overseeing defense attorneys, evaluating legal strategies, and engaging in negotiations for settlements. Comprehensive understanding of coverage analysis, liability evaluation, reserving practices, and strategies for resolving claims. Skilled in managing claims of moderate to high severity, with thorough documentation and well-justified decision-making. Capable of autonomously overseeing a caseload while adhering to set timelines and compliance requirements. Excellent written and spoken communication abilities, which encompass the creation of claim summaries, exposure assessments, and recommendations for settlement. Preferred Additional Background (Must be Combined with Claims Experience). Legal Background (Plus Claims Experience): Juris Doctor (JD), former attorney, or experience in litigation/paralegal work. Strong competency in reviewing pleadings, discovery materials, depositions, and legal risks. Clinical / Nursing Background (Plus Claims Experience): Registered Nurse (RN) or equivalent clinical qualification. Proficient in examining medical records and evaluating causation, the suitability of treatments, and adherence to care standards. Knowledgeable about senior living environments (nursing homes, assisted living facilities, etc.).