Sr. Claims Specialist, Medical Malpractice | Professional Liability

Sedgwick

23h

About The Position

The Sr. Claims Specialist analyzes complex or technically difficult medical malpractice claims, including highly complex matters and claims involving severe injuries. The role coordinates claim management in accordance with company standards, industry best practices, and client service requirements, while managing total claim costs and providing a high level of customer service. The specialist investigates and processes claims, develops action plans toward timely resolutions, negotiates settlements within designated authority, sets and monitors reserves, and recommends settlement strategies. The position also coordinates legal defense, monitors counsel and invoices, applies cost-containment approaches, and investigates opportunities for fraud detection, recovery, and case management. It involves communicating with clients, maintaining complete and accurately coded claim files, representing the company in legal proceedings as needed, and referring cases to management when appropriate. The role may include delegating work and mentoring assigned staff.

Requirements

Six years of claims management experience, or an equivalent combination of education and experience.
In-depth knowledge of applicable medical malpractice insurance principles and laws, recoveries, offsets and deductions, claim and disability duration, and cost-containment principles, including medical management practices and Social Security application procedures as applicable to the line of business.
Excellent oral and written communication and presentation skills.
Computer literacy, including Microsoft Office products.
Analytical and interpretive skills.
Strong organizational skills.
Excellent negotiation skills.
Good interpersonal skills.
Ability to work in a team environment.
Ability to meet or exceed Performance Competencies.
Licenses as required.
Ability to handle work-related stress, multiple priorities, and deadlines; clear and conceptual thinking, judgment, troubleshooting, problem-solving, analysis, and discretion.
Ability to perform computer keyboarding and travel as required; hearing, vision, and talking.

Nice To Haves

Bachelor’s degree from an accredited college or university.
Professional certification applicable to the line of business.

Responsibilities

Analyze and process complex or technically difficult medical malpractice claims; investigate and gather information to determine claim exposure and manage claims to timely resolution.
Conduct or assign full investigations and prepare 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 lifecycle.
Recommend settlement strategies and present structured settlement proposals when appropriate.
Coordinate legal defense, including assigning attorneys, supporting investigations, reviewing attorney invoices, and monitoring counsel’s 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 with 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.
Perform other duties as assigned.
Support the organization’s quality programs.