Senior Claims Specialist, HMO & PEI Claims

About the job

Working under moderate direction, this role manages a book of specialty lines claims across the full claim lifecycle — from initial investigation through settlement and closure. Analyzes, investigates, and evaluates losses to determine coverage and appropriate claim disposition Documents claims and sets diaries for follow-up and key events using CMS Establishes appropriate indemnity and expense reserves within assigned settlement authority, reviewing regularly to ensure adequacy; recommends reserve levels for claims exceeding authority Prepares comprehensive claim reports as required Identifies emerging claim trends and account or policy issues, communicating findings to management and underwriting Manages the litigation process, including retaining counsel and overseeing case resolution Ensures adherence to line-of-business litigation guidelines, including budget management, bill review, and payment Actively participates in mediations and arbitrations within assigned settlement authority Participates in the claims audit process May support claims marketing efforts by engaging with brokers, risk managers, and reinsurers Maintains required insurance adjuster licenses Bachelor's degree required; advanced degree preferred 5+ years of experience in claims handling, legal, or a related field Strong working knowledge of claims handling concepts, practices, and techniques, including coverage issues and product line expertise Solid understanding of insurance law and regulations across multiple jurisdictions Excellent verbal and written communication skills Strong negotiation skills, with the ability to resolve claims effectively within authority limits Experience handling HMO and Provider Excess Claims