Claims Examiner - Commercial Healthcare

Healthcare Claims Examiner

As the Healthcare Claims Examiner, you will directly handle Commercial Healthcare Claims across the U.S.

Key Accountabilities/Deliverables:

• Ensure compliance with established claim handling guidelines regarding coverage, investigation, liability, damages, evaluation, and resolution.
• Provide oversight on claims portfolios within the primary casualty book. Maintain direct contact with insureds, agents, and brokers.
• Provide oversight on claims portfolios handled by TPAs within the excess casualty book.
• Engage in rigorous ALAE control and management, by competently selecting, instructing, and managing 3rd party vendors, as appropriate.
• Gather and analyse information necessary to make an accurate evaluation of the claim by delivering effective resolution of claims, make decision within established authority levels and identifying settlement issues.
• Establish reserves pursuant to established reserving protocols and reserve authority procedures.
• Successfully and proactively resolve complex and/or high exposure claims, promptly limiting exposure to the Company. Substantial involvement in mediation negotiations will be required.
• Adhere to the Panel Counsel Program and all Litigation Management Guidelines.
• Meet all Reporting Requirements by completing reports timely and accurately, including Large Loss Reports, etc.
• Liaise and attend meetings with the underwriting team regarding claim trends and other areas of interest.
• Work with external customers to address questions, resolve problems and maintain rapport.
• Occasional domestic travel may be required to attend mediations and/or trials.
• Undertaking general office administrative duties as and when required.
• Proactively expanding and maintaining awareness of the current market/industry and attend continuing education programs when available.
• In addition to the above key responsibilities, you may be required to undertake other duties from time to time as the Company may reasonably require.

Technical Knowledge and Understanding:

• Must possess a general understanding and knowledge of state and federal laws as they apply to US Specialty Healthcare claims.
• Must possess a general understanding of policy language/coverages applicable to US Specialty Healthcare.
• Must understand medical terminology.

Experience:

• College degree required or equivalent experience
• Must be licensed as a claims adjuster in their home state multi-state licensure is preferred.
• A minimum of 3 years of claims adjusting or legal experience is required. A background in US Healthcare Professional/General Liability is preferred.
• A prior history of employment as a Healthcare professional or Medical Malpractice attorney is a plus.
• Must have experience handling Primary and Excess claims. Additional experience handling Reinsurance is preferred.
• Ability to travel for meetings, mediations and trials as required.
• Ability to negotiate and be persuasive.
• Possess strong communication and writing skills.
• Must be detail oriented and organized.
• Must possess the ability to work independently and as a team member.
• Must be a self-starter and possess problem solving skills.
• Must be able to manage pending caseloads, additional projects and meet all deadlines as set by management

Applicants must be authorized to work for any employer in the U.S. We are unable to sponsor or take over work authorization sponsorship now or in the future for this position.

At Core Specialty, you will receive a competitive salary and opportunities for professional development and advancement. We offer medical, dental, vision, and life insurances; short and long-term disability; a Company-match of 100% of a 6% contribution 401(k) plan; an Employee Assistance Plan; Health Savings Account, Flexible Spending Account, Health Reimbursement Account, and a wellness program