Complex Claims Specialist

Own and manage LTC Professional Liability Claims from first notice through resolution: investigate, analyze coverage, evaluate liability and damages, establish and adjust reserves, negotiate settlements and close files within authority. Perform advanced coverage analysis (duty to defend vs. indemnify, occurrence vs. claims-made, allocation, additional insured issues, contractual liability, tail exposures, endorsements) and prepare clear coverage opinions and reservation of rights/declination communications.

Document claims thoroughly using Claims Management System and proactively diary follow-up actions and deadlines. Set indemnity and expense reserves within authority; escalate and recommend reserves for matters outside authority; review reserves regularly and justify reserve positions to management and auditors. Manage litigation: retain and oversee outside defense counsel with LTC expertise, control budgets and billing, direct discovery strategy, and evaluate mediation/arbitration/trial risk to optimize resolution.

Coordinate clinical resources and expert consultants (nursing, pharmacy, infection control, medical specialists) for chart review, causation analysis and expert testimony. Interface with regulatory, compliance and risk management teams on CMS/state surveys, licensing investigations and mandatory reporting; incorporate regulatory developments into case strategy.

Collaborate with underwriting, reinsurance and subrogation on allocation, ceded reporting and recovery opportunities. Identify and report claim trends, coverage exposures and policy issues to management and underwriting; contribute to playbooks, training and process improvements. Participate in mediations and arbitrations within settlement authority and support major loss response efforts.

Maintain required adjuster licenses and adhere to company litigation and billing guidelines. Bachelors' and/or advanced degree. J.D. is a plus! 7 + years claims/legal experience, with at least 2 years within a technical specialty preferred. Healthcare Claims experience strongly desired (Long-Term Care Professional Liability, Miscellaneous Medical Facilities and/or Group Practice claims).

Advanced knowledge of claims handling concepts, practices and techniques, to include but not limited to coverage issues, and product line knowledge. Functional knowledge of law and insurance regulations in various jurisdictions. Demonstrated advanced verbal and written communications skills. Demonstrated advanced analytical, decision making and negotiation skills.

Obtain and maintain Adjuster's license.