Senior Claims Examiner

Role Description

Reporting to the Claims Manager or Chief Claims Officer, and working independently and with great latitude for independent action, the Senior Claims Examiner manages an inventory consisting primarily of claims with higher loss potential and complexity, and commensurate reserving, settlement authority, reinsurance reporting requirements, as well as claims of lesser exposure or severity as dictated by the needs of the department. Investigates, evaluates and settles claims within designated authority. Occasionally assigns and directs Independent Adjusters/Appraisers and regularly assigns and directs defense attorneys.

Responsibilities

• Determines coverage(s) applicable to loss.
• Investigates, manages and resolves claims in a timely, unbiased and informed manner in compliance with company policies, state laws and regulatory performance standards.
• Sets and maintains adequate claim reserves based on facts of case and in accordance with company policy.
• Conducts investigation, assigning fieldwork as necessary and appropriate, in accordance with company standards.
• Determines liability.
• Evaluates and pays claims within designated authority.
• When requested, present coverage and claims analysis to management and make recommendations on resolution of disputed items.
• Set reserves up to the positions level of authority.
• Prepares and presents verbal and written claim status reports in accordance with company policy and pursuant to Reinsurance treaty requirements.
• Recommends payment, evaluates and reserves claims and reports to manager cases in excess of designated authority, as well as to Reinsurers pursuant to treaty requirements.
• Manages legal aspects through timely assignment of litigated cases to defense counsel, and on-going evaluation of legal process and expenses.
• Maintain electronic files necessary for documentation of the claim file.
• Analyzes and regularly reports to Claims Manager on the performance of defense counsel.
• Represents the company at litigation related settlement conferences, mediation, and arbitration when needed.
• Works closely with outside counsel to monitor claims and work with insureds to resolve underlying litigation.
• Participates in both internal and external audits as needed.
• Participates in weekly department meetings and Claims Committee Meetings as needed.
• Promote the team approach to case and account management.
• Participates in marketing presentations and training programs as needed.
• Provide accurate, courteous and timely information to all external and internal customers concerning claims status and other inquiries.
• Other duties as assigned.

Qualifications

• Requires highly technical claim management skills, and significant knowledge of and experience with more than one of the following: Employment Practices Liability, Social Service Professional, Sexual Abuse, General Liability, and/or Business Auto; or Commercial Property expertise.
• Ability and willingness to obtain adjuster licenses as needed in various states.
• Demonstrate a thorough knowledge of current tort law and case law trends with respect to all casualty lines of business, civil procedure, insurance policy(s) and contract(s).
• Good written and oral communication skills.
• Organized and possess strong follow-up skills.
• Ability to analyze and apply creative solutions to claim issues.
• Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details.
• Strong negotiating skills, excellent telephone, written and verbal communication skills are essential.
• Objectivity and pragmatism as well as strong conflict resolution skills.
• Ability to manage total loss cost outcomes including ALAE to achieve superior results for our members and the company.
• Aware of and follow guidelines concerning confidentiality.
• Communicates with legal and medical personnel, third party claimants, policyholders, producers, Reinsurers, and senior level staff throughout the company.
• Demonstrated capability for working with a high level of independence.
• Ability to deliver results in a fast-paced environment.
• Positive approach, can-do attitude, flexibility and ability to operate with grace under pressure.
• Ability to model and uphold appropriate professional boundaries in work with member-insureds.
• Collaborate with other staff members and external partners.
• Interest and commitment to the mission of the organization.
• Commitment to inspired service.
• Communicate effectively orally and in writing.
• While performing the duties of this job, the employee is regularly required to bend, reach or sit for up to 3 hours at a time.
• Must have adequate vision (with corrective lenses, or other accommodative devices if needed) to clearly view computer screen.
• Must have adequate hearing to perform job tasks.
• PC literacy required; proficiency in Windows, Word, and Outlook preferred.
• Travel required as necessary and must be able to be productive while traveling on business, including the ability to utilize laptops and other business tools as provided, subject to reasonable accommodation, if needed.
• Ability to mentor peer groups or more junior claims staff, as requested.

Experience

• The position generally requires a minimum of ten or more years of progressively more difficult claims handling experience.

Education

• Four year college degree or equivalent business experience.