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

Sedgwick•New York, NY

About The Position

The Sr. Claims Specialist analyzes complex or technically difficult medical malpractice claims and resolves claims that are highly complex or involve severe injuries. The role coordinates case management in accordance with company standards, industry best practices, and client service requirements while managing total claim costs and providing high levels of customer service. The specialist investigates claims and legal actions, develops action plans toward timely resolution, negotiates settlements within designated authority, calculates and monitors reserves, and recommends settlement strategies. The role also coordinates legal defense, monitors counsel and invoices, applies cost-containment techniques, and identifies opportunities for fraud investigation, subrogation, contribution, recovery, and case management. The specialist communicates with clients, maintains claim documentation and accurate coding, represents the company in depositions, mediations, and trial monitoring as needed, and may delegate work and mentor assigned staff. The position also supports organizational quality programs and performs other duties as assigned.

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 applicable medical malpractice insurance principles and laws, recoveries, offsets and deductions, claim and disability duration, cost-containment principles including medical management practices, and Social Security application procedures as applicable to the line of business.
Excellent oral and written communication skills, including presentation skills.
Computer literacy, including Microsoft Office products such as 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 meet deadlines and demonstrate clear and conceptual thinking, excellent judgment, and discretion.

Nice To Haves

Juris Doctor degree.
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 using well-developed action plans to achieve appropriate and timely resolutions.
Conduct or assign full investigations and provide investigation 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 reserve adequacy throughout the claim life.
Recommend settlement strategies and present structured settlement proposals as necessary to maximize settlement.
Coordinate legal defense, including assigning attorneys, coordinating investigative support, reviewing attorney invoices, and monitoring counsel compliance with client guidelines.
Use cost-containment techniques, including strategic vendor partnerships, to reduce 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 monitor trials as needed.
Communicate claim activity and processing to clients and maintain professional client relationships.
Ensure claim files are properly documented and claims coding is correct.
Refer cases to supervisors and management as appropriate.
Delegate work and mentor assigned staff.
Support the organization's quality programs.
Perform other duties as assigned.