Complex Claims Consultant - Hospitals , Allied Facilities and Physicians

About the role

This individual contributor position works under general direction, and within broad authority limits, to manage complex hospitals, allied facilities, and physicians claims with high complexity and exposure for a specialized line of business. Responsibilities include the coordination of all claim resolution activities in accordance with company protocols, while achieving quality and customer service standards. The role requires regular communication with customers and insureds and may have regional, industry segment, or company-wide scope of responsibility.

Responsibilities

• Manages an inventory of highly complex healthcare claims, with large exposures that require a high degree of specialized technical expertise and coordination, by following company protocols to verify policy coverage, conduct investigations, develop and employ resolution strategies, and authorize disbursements within authority limits.
• Ensures exceptional customer service by managing all aspects of the claim, interacting professionally and effectively, achieving quality and cycle time standards, providing timely updates, and responding promptly to inquiries and requests for information.
• Verifies coverage and establishes timely and adequate reserves by reviewing and interpreting policy language, partnering with coverage counsel on more complex matters, estimating potential claim valuation, and following company's claim handling protocols.
• Leads focused investigations to determine compensability, liability, and covered damages by gathering pertinent information, such as contracts or other documents, taking recorded statements from customers, claimants, injured workers, witnesses, and working with experts or other parties as necessary to verify the facts of the claim.
• Resolves claims by collaborating with internal and external business partners to develop, own, and execute a claim resolution strategy, including management of timely and adequate reserves, collaborating with coverage experts, negotiating complex settlements, partnering with counsel to manage complex litigation, and authorizing payments within scope of authority.
• Establishes and manages claim budgets by achieving timely claim resolution, selecting and actively overseeing appropriate resources, authorizing expense payments, and delivering high-quality service in an efficient manner.
• Realizes and addresses subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making referrals to appropriate Claim, Recovery, or SIU resources for further investigation.
• Achieves quality standards by appropriately managing each claim to ensure that all company protocols are followed, work is accurate and timely, all files are properly documented, and claims are resolved and paid timely.
• Keeps senior leadership informed of significant risks and losses by completing loss summaries, identifying claims to include on oversight/watch lists, and preparing and presenting succinct summaries to senior management.
• Maintains subject matter expertise and ensures compliance with state/local regulatory requirements by following company guidelines and staying current on commercial insurance laws, regulations, or trends for the line of business.
• Mentors, guides, develops, and delivers training to less experienced Claim Professionals.
• May perform additional duties as assigned.

Requirements

• Bachelor's Degree or equivalent experience.
• Typically a minimum of six years of relevant experience, preferably in claim handling.
• Must have or be able to obtain and maintain an Insurance Adjuster License within 90 days of hire, where applicable.
• Prior negotiation experience.
• Professional designations preferred (e.g., CPCU).

Skills & Qualifications

• Thorough knowledge of the commercial insurance industry, products, policy language, coverage, and claim practices.
• Strong communication and presentation skills, both verbal and written, including the ability to communicate business and technical information clearly.
• Demonstrated analytical and investigative mindset with critical thinking skills and the ability to make sound business decisions, effectively evaluate, and resolve ambiguous, complex, and challenging business problems.
• Strong work ethic, with demonstrated time management and organizational skills.
• Ability to work in a fast-paced environment at high levels of productivity.
• Demonstrated ability to negotiate complex settlements.
• Experience interpreting complex commercial insurance policies and coverage.
• Ability to manage multiple and shifting priorities in a fast-paced and challenging environment.
• Knowledge of Microsoft Office Suite and ability to learn business-related software.
• Demonstrated ability to value diverse opinions and ideas.
• Innovative and adaptive to evolving Claims environment, including incorporating the use of AI as appropriate in handling claims.

Pay

In District of Columbia, California, Colorado, Connecticut, Illinois, Maryland, Massachusetts, New York, and Washington, the national base pay range for this job level is $72,000 to $141,000 annually. Salary determinations are based on various factors, including but not limited to, relevant work experience, skills, certifications, and location.

Benefits

CNA offers a comprehensive and competitive benefits package to help employees—and their family members—achieve their physical, financial, emotional, and social well-being goals. For a detailed look at CNA’s benefits, please visit cnabenefits.com.