Claims Examiner - Commercial Healthcare

Core Specialty Insurance Holdings, Inc.•Cincinnati, OH

4d•Hybrid

About The Position

As the Healthcare Claims Examiner, you will directly handle Commercial Healthcare Claims across the U.S. This role involves ensuring compliance with established claim handling guidelines, providing oversight on claims portfolios, managing ALAE, and making accurate claim evaluations. You will establish reserves, resolve complex claims, adhere to litigation management guidelines, and meet reporting requirements. Additionally, you will liaise with the underwriting team, work with external customers, and potentially travel domestically for mediations and trials. General office administrative duties may also be required. Proactive market awareness and continuing education are encouraged.

Requirements

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.
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.
Must have experience handling Primary and Excess claims.
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.

Nice To Haves

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.
Additional experience handling Reinsurance is preferred.

Responsibilities

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.
Undertake other duties from time to time as the Company may reasonably require.