BASIC PURPOSE:
Responsible for handling large, complex claim files, including litigated matters, catastrophic claims, umbrella claims, punitive damage claims, severe injury, long duration indemnity, permanent total disability, structural building damage, multiple location damage, including business income exposure and other extensive exposure claims, in accordance with applicable state and federal laws. Set reserves and settle claims within level of authority. Direct work of defense attorney. Actively share knowledge with team members, contribute to training programs, and mentor other claim representatives. Stay abreast of current and emerging complex litigation claim settlement issues, trends, court decisions, plaintiff bar activities, and partner with key CM Group stakeholders to share information and analyze potential impacts on our products and chosen markets.
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. Deny losses within authority level, providing detailed explanation, citing facts, and policy language. Caseload will consist largely of the most complex, high exposure matters involving issues such as policy limits, excess coverage, layered coverages, total loss matters, permanent total disability claims, catastrophic injury, and other specialty type, unique claims.
Perform a thorough investigation based upon the type, complexity, and severity of the claim. Inspect loss sites as necessary. Upon completion of the investigation, analyze and evaluate the potential high exposure and extensive damages, including potential full or partial liability and compensability denials. Formulate and document an action plan based on the covered damages and injuries.
Determine and set reserves based on the most probable outcome of the claim, 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 payments within authority for covered losses.
Maintain a professional, courteous, and helpful approach when communicating in person, on the phone, through email, and other correspondence with internal and external customers, business partners, and brokers.
Provide knowledge and guidance to other claim handlers regarding claim strategy, coverage interpretations, and in-depth jurisdictional and legal nuances. Field questions from team members related to coverage/compensability decisions.
Investigate and refer identified claims to loss recovery services, as applicable.
Direct work of defense attorney through collaboration on claim strategy and resolution. Ensure defense attorney is adhering to litigation management guidelines. Manage claim expense by concluding vendor assignment when vendor is no longer adding value to the claim.
Engage in direct investigation, control, and settlement negotiations when outside adjusting and legal services are not necessary or available.
Attend mediations, depositions, and trials. Present complex claim files during roundtables and claims committee meetings.
Stay abreast of current and emerging complex litigation/claim settlement issues, trends, court decisions, and plaintiff bar activities.
Actively communicate and share knowledge of trends, litigation environment, and potential impacts with key CM Group stakeholders.
QUALIFICATIONS:
Bachelor's degree preferred. A combination of equivalent education and/or experience may be considered in lieu of a degree.
Evidence of continuing education in the insurance industry is required.
Additional legal education or law degree is highly desirable.
AIC and/or CPCU designation is highly preferred.
Typically, fifteen or more years in technical insurance claim roles with increasing responsibilities is required.
Ability to obtain and maintain state adjusting license requirements and complete continuing education requirements.
Advanced knowledge of recoveries such as subrogation, reinsurance, apportionment, and deductibles.
Advanced knowledge of reinsurance contracts, workers' compensation pools, second injury funds, etc.
Advanced negotiation skills.
Strong listening, verbal, and written communication skills.
Advanced knowledge of policy terminology, legal principles involving insurance, and emerging industry trends.
Effective planning and organization skills.
Ability to travel to inspect loss sites, attend mediations, depositions, etc.
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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