Bachelor's Degree or equivalent experience required.
3-5 years of managed care or related claims experience.
Strong knowledge of the legal system and litigation processes.
Proficient in Microsoft Excel and Word, with experience in Windows operating systems.
Excellent communication and customer relations skills.
Responsibilities
Investigate and resolve complex managed care claims.
Analyze coverage issues and negotiate settlements within authority.
Review claims for proper reserves and monitor their adequacy.
Oversee the litigation process and maintain communication with defense counsel.
Attend mediations, court conferences, and trials as needed.
Prepare claim status reports and present at internal meetings.
Engage in cross-departmental collaboration and support business development.
Benefits
Opportunities for professional development and growth.
Collaborative work environment with supportive leadership.
Involvement in diverse projects within the company.
Participation in marketing and client engagement activities.
Full Job Description
TDCSU is currently seeking a Senior Claims Specialist to handle primary and excess managed care claims that involve moderate and potentially significant severity and complexity.
Working under the general supervision of VP of Claims and acting within authority appropriate to this position, the Senior Claims Specialist role is composed of the following responsibilities:
Investigate, evaluate and resolve claims with strong technical knowledge in managed care. The Senior Claims Specialist role is expected to independently and pro-actively manage managed care claims and establish a plan of action to achieve a favorable claim resolution. The Senior Claim Specialist is expected to demonstrate proficiency in the following:
Identifying and analyzing coverage issues
Negotiating claim settlement within authority level
Reviews files for timely and appropriate reserves; monitors reserve adequacy throughout the life of a claim file
Selects defense counsel within authority
Manages litigation process including ongoing communication with defense counsel, monitoring of legal status reporting, reviewing invoices and ensuring compliance with litigation guidelines
Attends mediations, court conferences and trials
Regularly communicates with the insured from initial contact to claim resolution
Regularly communicates with outside counsel as appropriate
Formulates and executes claim resolution plans
Promptly pays all claim expenses and indemnity obligations including the reporting of claim outcomes to state and federal regulatory agencies
Presents claims at internal claim roundtables
Prepares claim status reports to reinsurers
Regularly reviews quarterly loss runs for increase in reserves or severity matters, alerting management for potential impact to the TDCSU policies
Engages in collaborative projects in support of other areas in the company.
The position also requires providing support to our Segment Leaders and Business Development Department. Attends marketing calls. Actively participates in pre-bind calls and visits with insureds and broker
Preferred Candidates
Should possess strong knowledge of relevant legal decisions, claim trends and industry practices. Strong technical knowledge in managed care claims. Additionally, it is important that the candidate have a demonstrated track record for professional commitment, curiosity, resourcefulness and a focus on tenaciously achieving outcomes that support our key business objectives.
Requirements
Possess strong knowledge of the legal system, litigation, claims trends, and industry practices.
Superior Communication and customer relations skills.
Bachelor's Degree or equivalent combination of education and experience required.
Three to five (3-5) years of managed care or equivalent claims-related experience.
Proficiency with Excel, Word and demonstrated aptitude with Windows based operating systems
About Doctors Co
The Doctors Company is a medical malpractice insurance company that provides professional liability insurance to physicians, surgeons, and other healthcare professionals. The company offers coverage for medical malpractice claims, as well as risk management and patient safety programs. The Doctors Company was founded in 1976 and is headquartered in Napa, California. The company has over 1000 employees and serves over 82,000 members nationwide.
