Claims Specialist

HR Recruiting Services•Orange, CA

13d

About The Position

The Senior Claims Specialist plays a critical role in the effective management of complex medical malpractice claims within the Orange County office. This position requires a high level of technical expertise, attention to detail, and leadership in overseeing both claim resolution and team development. Under supervision, the Specialist is responsible for managing high-exposure, intricate claims from inception to resolution, including oversight of defense counsel, litigation coordination, and compliance with internal guidelines and agreements. In addition to core claims duties, the role includes mentoring and training Claims Specialists I and II, contributing to process improvement, and supporting management initiatives. The position demands strong analytical, organizational, and communication skills, along with a commitment to operational excellence and regulatory compliance.

Requirements

Bachelor’s degree from a four-year college or university.
Relevant legal and/or medical education background or equivalent experience.
Minimum five years of medical malpractice claims management experience, or three years of CAP claims experience.
Excellent verbal and written communication skills.
Proven ability to manage multiple priorities and meet tight deadlines.
Strong analytical and problem-solving abilities.
Proficient in personal computer applications and claims management systems.
Valid California driver’s license.

Responsibilities

Manage medical malpractice claims, including the assignment, direction, and control of defense counsel, in full compliance with the Claims Technical Manual, Defense Attorney Guidelines, and MPT Agreement.
Investigate and evaluate claim files by conducting member interviews, reviewing medical records, corresponding with plaintiff attorneys, obtaining preliminary expert opinions, and preparing detailed interview summaries.
Prepare comprehensive case evaluation reports for submission to the CRC and CSC, as well as for discretionary authority decisions on select cases.
Lead and participate in all litigation activities, including discovery planning, mediation, MSC proceedings, and settlement negotiations, under appropriate supervision.
Monitor trial and arbitration proceedings, providing daily progress updates and ongoing support to members and defense counsel.
Prepare and maintain accurate claim file resolution documentation, ensuring timely and complete updates to the claims database.
Maintain detailed chronologies of case developments and ensure all documents are properly coded, indexed, and uploaded to the On Base system.
Address coverage issues by identifying, investigating, and following up on relevant concerns.
Respond to hotline inquiries as needed, preparing and managing hotline documentation.
Support management with special projects and initiatives as assigned.
Contribute to the training and professional development of Claims Specialists I and II.
Attend required staff and department meetings and fulfill other duties as assigned.