Sr. Claims Specialist, Professional Liability | Medical Malpractice | New York City

Sedgwick•New York, NY

9d•$120,000 - $135,000

About The Position

The Sr. Claims Specialist analyzes complex or technically difficult medical malpractice claims, including highly complex matters and severe injury claims. The role coordinates case management in accordance with company standards, industry best practices, and client service requirements while managing total claim costs and providing strong customer service. The specialist investigates and processes claims, develops action plans for timely resolution, negotiates settlements within designated authority, assigns and monitors reserves, and recommends settlement strategies. The role coordinates legal defense, reviews attorney invoices and compliance with client guidelines, uses cost-containment practices, and identifies opportunities for fraud investigation, recovery, subrogation, contribution, and case management. The specialist may represent the company in depositions, mediations, and trial monitoring; communicates claim activity to clients; maintains accurate claim files and coding; and refers cases to management as appropriate. The position also delegates work, mentors assigned staff, and supports the organization's quality programs.

Requirements

Six years of claims management experience, or an equivalent combination of education and experience.
Bachelor's degree from an accredited college or university.
Licenses as required.
In-depth knowledge of medical malpractice insurance principles and applicable laws for the handled line of business, recoveries, offsets and deductions, claim and disability duration, cost-containment principles, medical management practices, and Social Security application procedures as applicable.
Excellent oral and written communication skills, including presentation skills.
Computer literacy, including Microsoft Excel, Word, and Teams.
Analytical and interpretive skills.
Strong organizational and time-management skills.
Excellent negotiation skills.
Good interpersonal skills.
Ability to work in a team environment.
Ability to meet or exceed Performance Competencies.
Ability to perform computer keyboarding and the hearing, vision, and talking requirements of the role.
Clear and conceptual thinking ability, excellent judgment and discretion, and ability to meet deadlines.

Nice To Haves

Juris Doctor.
Professional certification applicable to the line of business.

Responsibilities

Analyze and process complex or technically difficult medical malpractice claims by investigating and gathering information to determine claim exposure.
Manage claims through developed action plans to appropriate and timely resolution.
Conduct or assign full investigations and prepare reports concerning new events, claims, and legal actions.
Negotiate claim settlements up to the designated authority level.
Calculate and assign timely, appropriate reserves and monitor their adequacy throughout the claim lifecycle.
Recommend settlement strategies and present structured settlement proposals when appropriate.
Coordinate legal defense, including assigning attorneys, supporting investigations, reviewing attorney invoices, and monitoring compliance with client guidelines.
Use cost-containment techniques, including strategic vendor partnerships, to reduce overall client claim costs.
Identify and investigate potential fraud, subrogation, contribution, recovery, and case-management opportunities to reduce total claim costs.
Represent the company in depositions and mediations and conduct trial monitoring as needed.
Communicate claim activity and processing to clients and maintain professional client relationships.
Ensure claim files are properly documented and claim coding is correct.
Refer cases to supervisors and management as appropriate.
Delegate work and mentor assigned staff.
Perform other duties as assigned.
Support the organization's quality programs.