Complex Loss Specialist

Job Summary: The Complex Loss Specialist position at Golden State Claims Services reports to a Claims Supervisor or Claims Manager and specializes in complex claims. The role involves adjusting the most time-intensive, complex, and high-exposure losses requiring advanced technical expertise, knowledge, and negotiation skills. The specialist will provide analysis and presentations to Senior Executives and Program Executives, leading strategic discussions to determine optimal resolution strategies.

Position Responsibilities:

• Collaborate in a team environment by demonstrating teamwork, motivation, positive behavior, and effort to achieve goals and objectives.
• Build and maintain productive relationships with internal and external customers, including clients, underwriting and service teams, and agents.
• Research applicable coverage for insureds, documenting coverage dates, limits, and restrictions.
• Identify and resolve potential coverage questions, drafting reservation of rights and coverage denials for review and approval.
• Investigate loss facts by securing statements and supporting documentation such as contracts, repair estimates, expert reports, photos, and correspondence.
• Document activities in writing within claim files.
• Exercise judgment in applying legal liability to assigned claims, with settlement authority up to specific limits.
• Assign and manage defense counsel for lawsuits, monitoring and directing defense counsel, independent adjusters, and experts.
• Identify claims with potential exposure exceeding authority and advise the Supervisor/Manager.
• Evaluate, set, or recommend reserves for each file.
• Prepare written reports as dictated by company policy and procedures.
• Handle claims within guidelines of the Fair Claims Practices 790.03.
• Provide regular updates on file handling status to insureds, claimants, underwriters, and carriers.
• Discuss unique and complex files with the Supervisor/Manager.

Core Technical Duties:

• Investigate and evaluate healthcare liability claims, including medical malpractice, general liability, and professional liability exposures.
• Conduct coverage analysis and interpret policies, reviewing coverage dates, limits, exclusions, and endorsements.
• Draft reservation of rights letters and coverage denial communications for supervisor review.
• Evaluate, set, and recommend reserves based on exposure analysis and claim trajectory.
• Manage litigation, including assignment and direction of defense counsel, independent medical examiners, and expert witnesses.

Investigation & Documentation:

• Secure recorded and written statements from insureds, claimants, and witnesses.
• Gather and organize supporting documentation including incident reports, medical records, licensing records, contracts, and expert reports.
• Maintain accurate, detailed claim file documentation in compliance with carrier and program guidelines.
• Prepare written reports and roundtable summaries consistent with company policies and procedures.

Minimum Qualifications:

• Minimum of 10 years of claims experience, with an emphasis on complex claims.
• College degree or equivalent claims management experience required.
• Minimum of 10 years of litigation management experience preferred.
• Must hold an individual adjusting license for a designated home state and be willing to secure additional required adjusting licenses as needed.
• Active adjusters license under your name required.
• Proficient computer skills including Microsoft Outlook, Word, and Excel.
• Ability to maintain consistent and clear communication with leadership, the team, and all external points of contact.