Claims Examiner - Healthcare

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As the Healthcare Claims Examiner, you will directly handle Healthcare Claims.

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 educations 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.


* Computer skills – good working knowledge of Windows 10.

MS Office, Excel and basic computer setup/troubleshooting.


* Previous experience with an electronic (paperless) claim system.

Experience:


* College degree required.


* Must be licensed as a claims adjuster in their home state – multi-state licensure is preferred.  


* A minimum of 5 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 Med...