Complex Casualty Claims Specialist

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.
• Negotiates claim settlements with plaintiff’s attorneys.
• Completes litigation matters in CLMS and Claims Center claims systems.
• Sets and updates timely, adequate reserves in compliance with the company reserving philosophy and methodology.
• Prepares roundtable reports and large loss reports to advise the Branch VPs and Underwriting Directors.
• Identifies, investigates, and proactively pursues opportunities for recovery.
• 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 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.

Claims Investigation and Evaluation

• 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.
• 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.

Technical Resource

• 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

• Serves as a referral source 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.