About this role
- Own and manage LTC Professional Liability Claims from first notice through resolution: investigate, analyze coverage, evaluate liability and damages, establish and adjust reserves, negotiate settlements and close files within authority.
- Perform advanced coverage analysis (duty to defend vs. indemnify, occurrence vs. claims-made, allocation, additional insured issues, contractual liability, tail exposures, endorsements) and prepare clear coverage opinions and reservation of rights/declination communications.
- Document claims thoroughly using Claims Management System and proactively diary follow-up actions and deadlines.
- Set indemnity and expense reserves within authority; escalate and recommend reserves for matters outside authority; review reserves regularly and justify reserve positions to management and auditors.
- Manage litigation: retain and oversee outside defense counsel with LTC expertise, control budgets and billing, direct discovery strategy, and evaluate mediation/arbitration/trial risk to optimize resolution.
- Coordinate clinical resources and expert consultants (nursing, pharmacy, infection control, medical specialists) for chart review, causation analysis and expert testimony.
- Interface with regulatory, compliance and risk management teams on CMS/state surveys, licensing investigations and mandatory reporting; incorporate regulatory developments into case strategy.
- Collaborate with underwriting, reinsurance and subrogation on allocation, ceded reporting and recovery opportunities.
- Identify and report claim trends, coverage exposures and policy issues to management and underwriting; contribute to playbooks, training and process improvements.
- Participate in mediations and arbitrations within settlement authority and support major loss response efforts.
- Maintain required adjuster licenses and adhere to company litigation and billing guidelines.
- Bachelors' and/or advanced degree.
- J.D. is a plus!
- 7 + years claims/legal experience, with at least 2 years within a technical specialty preferred.
- Healthcare Claims experience strongly desired (Long-Term Care Professional Liability, Miscellaneous Medical Facilities and/or Group Practice claims).
- Advanced knowledge of claims handling concepts, practices and techniques, to include but not limited to coverage issues, and product line knowledge.
- Functional knowledge of law and insurance regulations in various jurisdictions.
- Demonstrated advanced verbal and written communications skills.
- Demonstrated advanced analytical, decision making and negotiation skills.
- Obtain and maintain Adjuster's license.