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Claims Specialist

• Serve as a subject matter expert in the Claims department
• Handle high-severity and high-complexity commercial claims
• Interpret policy documents and legal contracts
• Analyze and identify coverage and related coverage issues
• Apply knowledge of insurance contracts, claims practices, insurance codes, civil codes, vehicle codes, arbitration rules, regulations, and tort law
• Manage, investigate, and resolve claims within prescribed authority levels
• Recommend resolutions for cases exceeding authority to claims management
• Handle litigation involving General Liability and Casualty files
• Drive litigation and attend mediations, trials, and alternative dispute resolution proceedings
• Communicate with policyholders, witnesses, and claimants to gather claim information and advise on appropriate action
• Respond to written and telephone inquiries, including status reports
• Present file materials for authority reviews and roundtables
• Work with nurses, doctors, attorneys, and independent field adjusters on file reviews and claim-specific guidance
• Comply with statutory and regulatory requirements
• Meet quality assurance standards and performance goals
• Set and revise case reserves according to reserving policy
• Identify suspicious claims and refer them to SIU
• Identify third-party subrogation opportunities
• Maintain security of financial claim processing and information in claims files
• Partner with internal teams and advise leadership on claim activities and exposures