Senior Claim Representative / Claim Counsel

Davies•Home, WV

9h•$110,000 - $140,000•Remote

About The Position

The Claim Counsel / Senior Complex Representative manages high-severity and technically complex claims across healthcare and specialty professional liability programs. The portfolio may include Medical Malpractice and Healthcare Professional Liability, Miscellaneous Errors & Omissions, broker and insurance professionals E&O, claims involving third-party administrators and other insurance service providers, insurers’ extra-contractual liability exposures, and Directors & Officers Liability. Depending on program needs, the position may also handle general liability components of healthcare package policies and other related specialty exposures. The role serves as a subject matter resource to carriers and internal teams, providing independent evaluations of coverage, liability, damages, litigation posture, reserve adequacy, and resolution strategy. It is suited to an attorney with insurance coverage and complex claims experience or a senior claims professional with substantial experience in healthcare liability, professional liability, management liability, or other specialty lines.

Requirements

Juris Doctor (JD) with active bar membership in good standing, or generally 7–10+ years of senior-level experience handling complex healthcare liability, professional liability, management liability, insurance professionals E&O, or comparable specialty claims.
Active adjuster license(s), as required, and willingness to obtain and maintain additional licenses based on assigned jurisdictions.
Demonstrated expertise in insurance coverage analysis, policy interpretation, liability and damages evaluation, reserve analysis, and litigation strategy.
Experience drafting or substantively advising on coverage positions, including reservations of rights and denials.
Experience managing outside counsel, experts, mediations, and complex or high-severity litigation.
Excellent analytical, organizational, negotiation, reporting, written communication, and verbal communication skills.
Ability to independently manage multiple complex claims while meeting deadlines, reporting requirements, and service expectations.
Proficiency with claims management systems and standard business technology.

Nice To Haves

Experience across two or more of the following: healthcare professional liability, long-term care, miscellaneous E&O, broker or insurance professionals E&O, third-party administrator liability, insurers’ extra-contractual liability, or D&O.
Experience with both primary and excess claims, package policies, multi-insured matters, and matters involving overlapping professional liability and general liability exposures.
Experience in program business, delegated authority, third-party claims administration, or specialty insurance environments.
Familiarity with healthcare regulations, insurance operations, professional services contracts, directors’ and officers’ duties, and extra-contractual claim theories.
Experience working closely with carrier claim teams, coverage counsel, in-house legal teams, underwriting, or program management.

Responsibilities

Evaluate coverage issues across healthcare professional liability, miscellaneous and insurance professionals E&O, insurers’ extra-contractual liability, and D&O claims.
Analyze complex coverage questions, including claims-made and occurrence triggers, retroactive dates, prior knowledge and prior acts, interrelated claims, notice requirements, multiple insureds, and allocation between coverages.
Draft and issue coverage position letters, including reservations of rights and denials, and advise on policy forms and language.
Review policies, endorsements, applications, and applicable law to determine coverage, exclusions, conditions, limits, retentions, allocation, and other obligations.
Direct and conduct thorough investigations, reviewing pleadings, contracts, medical records, claim files, facility records, professional services documentation, correspondence, regulatory materials, and other evidence.
Coordinate with medical experts, nurses, facility personnel, administrators, and defense counsel on healthcare claims to assess standards of care, causation, clinical issues, and damages.
Analyze professional services or management duties, alleged errors or omissions, economic loss, reliance, causation, contractual obligations, regulatory considerations, and defenses for E&O and management liability claims.
Evaluate underlying claim-handling facts, settlement opportunities, communications, damages, and legal standards for extra-contractual claims.
Develop, document, and execute claim strategies, action plans, and litigation management plans tailored to program and carrier requirements.
Provide carriers with timely reports on material facts, coverage, liability, damages, reserves, litigation developments, and recommended next steps.
Select or work with approved defense counsel and experts, set expectations, monitor performance, and ensure compliance with litigation and billing guidelines.
Assess pleadings, dispositive motion opportunities, discovery strategy, expert needs, trial posture, and resolution options.
Evaluate exposure and establish or recommend reserves in accordance with carrier guidelines and delegated authority.
Develop settlement strategies and negotiate settlements within assigned authority; participate in mediations, settlement conferences, claim reviews, and other proceedings as required.
Identify opportunities for contribution, indemnity, contractual recovery, subrogation, or other risk transfer where applicable.
Ensure claims handling complies with Department of Insurance regulations and internal protocols, and maintain accurate documentation in the claims management system.
Advise carriers, program stakeholders, and internal teams on coverage, exposure, litigation strategy, and claim resolution.
Serve as a principal point of contact for policyholders, brokers, counsel, experts, healthcare providers, administrators, and other stakeholders.
Deliver client presentations on claim status and strategy, respond to carrier questions, and communicate complex legal, medical, financial, and coverage issues clearly to technical and non-technical audiences.
Maintain regular and dependable attendance and be available to perform job responsibilities during established work hours.

Benefits

Medical insurance
Dental insurance
Vision insurance
401(k) with employer matching
Discretionary Time Off (DTO) for exempt employees or Paid Time Off (PTO) for non-exempt employees
Paid holidays
Life insurance
Short-term disability coverage
Long-term disability coverage
Paid sick leave, paid family leave, and paid parental leave where required by law