BASIC PURPOSE:
In accordance with application of state and federal laws and company best practices, handle higher exposure, complex claims within an assigned line of coverage including multi-jurisdictional and litigated matters. Gather and review claim information, determine coverage, and conduct investigation. Initiate and maintain customer contact to provide updates and resolve any issues with the claim. Update information in the claim system to document claim handling activities. Determine/set reserves and make payments within level of authority. Investigate and refer identified claims to Loss Recovery Services as applicable. This role requires knowledge of coverage forms and claims handling for General Liability (GL), Auto Liability, Professional Liability (PL), Employment Practices Liability (EPL), and Directors & Officers (D&O) lines of business.
PRIMARY JOB RESPONSIBILITIES:
- Perform claim tasks timely and document claim files appropriately. Proactively manage claim activities to ensure fair claim resolution. Handle all claims in accordance with state and federal laws.
- Make complex coverage decisions by gathering information necessary to make an informed decision in a fair, equitable, and ethical manner. Provide detailed explanation, citing facts, and relevant policy language. Evaluate subrogation potential based on the applicability of policy language and/or governing state laws and statutes as appropriate.
- Perform a thorough investigation based upon the type, complexity, and severity of the claim. Upon completion of the investigation, analyze and evaluate the potential exposure and damages, including potential full or partial liability, compensability denials, and subrogation potential as applicable. Formulate and document an action plan based on the covered damages and injuries.
- Determine and set reserves based upon a risk-neutral evaluation of the most likely outcome within authority level. Evaluate and negotiate directly with insured, claimant, or claimant's attorney on all cases within authority level. Review claim facts and exposure with claims management as appropriate, to guide claim strategy. Make complete, accurate, and timely loss and/or expense payments within authority for covered losses. Refer claims above authority to appropriate team member for review and potential reassignment.
- Maintain a professional, courteous, and helpful approach when communicating in person, on the phone, or through email and other correspondence with internal and external customers, business partners and brokers
- Recognize when vendor partners are required on a claim, including experts, independent adjustors, nurses, defense attorneys, etc. Assign and direct vendors, as needed, to aid in the investigation and evaluation of the claim. Manage claim expense by reviewing attorney/firm performance, results and the value of services provided.
- Investigate and refer identified claims to Loss Recovery Services as applicable.
- Attend mediations and other litigation-related activities as needed
- Collaborate with defense counsel and direct litigation strategy.
QUALIFICATIONS:
- Bachelor's degree preferred. A combination of equivalent education and/or experience may be considered in lieu of a degree.
- Additional training in insurance, medical, and/or legal environments is desirable.
- Completion of INS, AIC, or CPCU is preferred.
- Minimum of five years of claim handling and/or other insurance-related experience is required.
- Ability to obtain and maintain state adjusting license requirements and complete continuing education requirements.
- Evidence of ability to think independently.
- Strong listening, verbal, and written communication skills.
- Ability to handle multi-jurisdictional and litigated claims.
- Proficient knowledge of policy terminology and legal principles involving at least one or more of the following: insurance, automobile, medical and litigated claims.
WORK ENVIRONMENT:
- Professional office environment.
NOTE: This job description in no way states or implies that these are the only duties performed by this employee. Employees may be requested to perform job-related tasks other than those specifically presented in this job description. The employer reserves the right to change or assign other duties to this position.
The CM Group is made up of Church Mutual Insurance Company, S.I., CM Regent Insurance Company, CM Vantage Specialty Insurance Company and CM Select Insurance Company.
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