Senior Claims Specialist, HMO & PEI Claims

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. The Claims Specialist conducts thorough investigations, recommends appropriate reserves, and resolves claims efficiently and cost-effectively within established authority limits for the line of business.

• →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