Complex Casualty Claims Specialist

The Complex Casualty Claims Specialist manages litigation of severely complex claims. Promptly investigates and evaluates severely complex auto and casualty claims identified as complex per EMC’s claims handling guidelines. Sets and updates timely, adequate reserves in compliance with the company reserving philosophy and methodology. Negotiates, settles and/or resolves severely complex claims.

Litigation Management:

Manages litigation of severely complex claims

Analyzes lawsuits by reviewing facts and allegations to determine coverage.

Prepares any Reservation of Rights letters and coverage position letters if warranted

Prepares lawsuit analysis and formalizes plan to discuss with management

Collaborates with defense counsel and others to prepare bodily injury and/or damage evaluations, negotiation ranges and target settlement numbers prior to negotiation.

Obtains higher authority when appropriate

Negotiates claim settlements with plaintiff’s attorneys

Completes litigation matters in CLMS and Claims Center claims systems

Assigns files and collaborates with defense counsel on action plans and litigation strategy to manage litigation expenses and obtain favorable outcomes

Secures all necessary official reports, claim forms and documents

Reviews legal budget, invoices, and litigation related expenses for accuracy and appropriateness

Identifies, investigates, and proactively pursues opportunities for recovery

Oversees suits, attends trials and mediations and assists with arbitrations, and depositions

Promptly investigates and evaluates claims of severe complexity:

Reviews the claim notice, contracts, state statutes and policies to verify the appropriate coverage, deductibles, and payees

Investigates and evaluates complex coverage issues to determine applicable coverage, partnering with EMC Coverage Counsel and/or outside counsel as appropriate

Initiates timely contact with insureds and claimants to explain the claim process and initiate the investigation

Obtains statements from insureds, claimants, and witnesses and documents summaries within the claims system

Requests and analyzes investigative and other relevant reports, claim forms and documents when appropriate

Documents claim activities, reserve analysis, summaries of reports including Medicare (MSP) modules in the claim system

Prepares claims and participates in claims roundtables to discuss unique cases to evaluate coverage, liability, and damages

Sets timely, adequate reserves in compliance with the company reserving philosophy and methodology and prepares roundtable reports and large loss reports to advise the Branch VPs and Underwriting Directors

Identifies, investigates, and proactively pursues opportunities for recovery including partnering with attorneys and/or other experts to arrange of evidence preservation in legal compliance that meets custody, control, transfer, analysis, and disposition of physical and/or electronic evidence

Adheres to all state requirements regarding regulatory compliance by sending out letters/forms containing appropriate language according to timelines

Recommends and obtains authority from Supervisor/Director in the assignment of defense counsel

Notifies people leader of claims that may need escalation or reassignment

Assigns and manages experts and third-party vendors for accuracy and appropriateness with supervisory approval as required

Drafts reservation of rights and denial letters when appropriate

Provides prompt, detailed responses to agents, insureds and claimants on the status of claims

Negotiates, settles and/or resolves claims:

Resolves questions of coverage, liability and the value of the claims and communicates with insureds and claimants to resolve claims in a timely manner

Prepares bodily injury and/or damage evaluations, negotiation ranges and target settlement numbers prior to negotiation. Obtains higher authority when appropriate

Identifies and protects all liens as appropriate

Investigates Medicare liens and timely resolve in accordance with EMC and Medicare guidelines

Communicates with insureds, claimants, and attorneys to negotiate the settlement of claims

Prepares and issues settlement and release documents verifying accuracy and ensuring they are properly executed

Reviews and audits estimates written by independent adjusters, engineers and other vendors for accuracy and to ensure the most cost-effective repair approach

Handles complex claims timely payment

Serves as a technical resource for team members:

Provides guidance to team members with technical issues of a claim and answers questions on coverage, compensability, investigations and plans of action.

Serves as a subject matter expert for other claims team members.

Handles complex claims nationwide

Acts as a technical resource to other claims professionals providing guidance on claims handling practice. Assists other claims professionals with complex or problematic claims as necessary

Leads and/or participates in claims projects as a representative of complex casualty claims

Collaboration:

Submits referrals to the Estimatics, Special Investigation, Subrogation, Medical Review Units, Corporate Office Coverage Counsel and outside coverage counsel as appropriate

Prepares risk reports for Underwriting and Risk Improvement

Reviews coverage intent and policy activity with Underwriting

Reviews account inspection information with Risk Improvement

Prepares claims and participates in claims roundtables to discuss unique cases to evaluate coverage and damage

Bachelor’s degree or equivalent relevant experience

Ten years of casualty claims adjusting experience or related experience

Relevant insurance designations preferred