Sr. Claims Specialist

Client: Sedgwick Claims Management Services, Inc.
 
Title: Sr. Claims Specialist – Medical Malpractice
 
Req #: 526805
 
Location: 290-300 Broadhollow Road, Suite 215W Melville NY 11747-4801
 
Duration: Direct Hire
 
Shift Hours: 7.5 hrs per day, 5 days/week
 
Claims Line of Business: PL – Professional Liability
 
SHORT DESCRIPTION:
 
Sr. Claims Specialist – Medical Malpractice
 
PRIMARY PURPOSE:
 
To analyze complex or technically difficult medical malpractice claims; to provide resolution of highly complex nature and/or severe injury claims; to coordinate case management within Company standards, industry best practices and specific client service requirements; and to manage the total claim costs while providing high levels of customer service.
 
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
 
·         Analyzes and processes complex or technically difficult medical malpractice claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
·         Conducts or assigns full investigation and provides report of investigation pertaining to new events, claims and legal actions.
·         Negotiates claim settlement up to designated authority level.
·         Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout claim life.
·         Recommends settlement strategies; brings structured settlement proposals as necessary to maximize settlement.
·         Coordinates legal defense by assigning attorney, coordinating support for investigation, and reviewing attorney invoices; monitors counsel for compliance with client guidelines.
·         Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall claim cost for our clients.
·         Identifies and investigates for possible fraud, subrogation, contribution, recovery, and case management opportunities to reduce total claim cost.
·         Represents Company in depositions, mediations, and trial monitoring as needed.
·         Communicates claim activity and processing with the client; maintains professional client relationships.
·         Ensures claim files are properly documented and claims coding is correct.
·         Refers cases as appropriate to supervisor and management.
·         Delegates work and mentors assigned staff.
 
ADDITIONAL FUNCTIONS AND RESPONSIBILITIES:
 
·         Performs other duties as assigned.
·         Supports the organization's quality program(s).
 
EDUCATION & LICENSING:
 
·         Bachelor's degree from an accredited college or university preferred. Licenses as required. Professional certification as applicable to line of business preferred.
 
EXPERIENCE:
 
·         Seven (7) years of claims management experience or equivalent combination of education and experience required.
 
SKILLS & KNOWLEDGE:
 
·         In-depth knowledge of appropriate medical malpractice insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security application procedures as applicable to line-of-business
·         Excellent oral and written communication, including presentation skills
·         PC literate, 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
 
Best,
Kushal Shah
APN Software Service INC
kushal@apninc.com

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