Complex Loss Specialist (Allied Health)

Job Summary

The Complex Loss Specialist position at Golden State Claims Services reports to a Claims Supervisor or Claims Manager and will specialize in Allied Health claims. The chief duty of the Complex Loss Specialist for Allied Health claims is to adjust the most time-intensive, complex, and high exposure losses that require a higher level of technical expertise, knowledge, and negotiating ability, for the program(s) to which is assigned. The Complex Loss Specialist will have a high level of ability to provide analysis and presentations to Senior Executives and Program Executives for these complex matters and will be well-versed in leading strategic roundtable discussions to determine optimal resolution strategy.

Position Responsibilities

• Contribute to a collaborative environment by consistently demonstrating teamwork, high motivation, positive behavior, and effort to achieve goals and objectives.
• Building and maintaining productive relationships with internal and external customers, including clients, underwriting and service teams, and agents
• Research applicable coverage for our insureds. Document coverage dates, limits, and restrictions
• Identify and resolve any potential coverage questions. Draft reservation of rights and coverage denials for review and approval by their Supervisor/Manager
• Investigate facts of the loss by securing statements and supporting documentation such as contracts, cost of repair estimates, expert reports, photos, correspondence, etc.
• Document activities in writing within claim files
• Exercise judgment in applying legal liability to assigned claims and will have settlement authority up to their specific authority, which may vary from carrier to carrier.
• Assign defense counsel to answer and defend lawsuits where appropriate. Monitor and direct defense counsel, independent adjusters, and experts.
• Identify claims with potential exposure in excess of authority and advise their Supervisor/Manager
• Evaluate, set, or recommend reserves for each file they are handling.
• Prepare written reports as dictated by company policy and procedures.
• Handle claims within guidelines of the Fair Claims Practices 790.03
• Provide insureds, claimants, underwriters, and carriers with regular updates on status of file handling.
• Discuss unique and complex files with Supervisor/Manager

Core Technical Duties

• Healthcare liability claims investigation and evaluation, including medical malpractice, general liability, and professional liability exposures
• Coverage analysis and interpretation of allied health professional liability policies, including review of coverage dates, limits, exclusions, and endorsements
• Medical record review and interpretation across allied health disciplines (physical therapy, home health, diagnostics, behavioral health, etc.)
• Drafting reservation of rights letters and coverage denial communications for supervisor review
• Reserve evaluation, setting, and recommendation based on exposure analysis and claim trajectory
• Litigation management, including assignment and direction of defense counsel, independent medical examiners, and expert witnesses

Investigation & Documentation

• Securing recorded and written statements from insureds, claimants, and witnesses
• Gathering and organizing supporting documentation including incident reports, medical records, licensing records, contracts, and expert reports
• Maintaining accurate, detailed claim file documentation in compliance with carrier and program guidelines
• Preparing written reports and roundtable summaries consistent with company policies and procedures

Minimum Qualifications

• Minimum of 10 years of claims experience, with an emphasis on complex Allied Health claims
• College degree or equivalent claims management experience required.
• Minimum of 10 years litigation management experience preferred.
• Must hold an individual adjusting license for a designated home State and be willing to secure additional required adjusting licenses as needed
• Active adjusters license under your name required
• Proficient computer skills including Microsoft Outlook, Word, and Excel.
• Ability to maintain consistent and clear communication with leadership, the team and all other external points of contact