Complex Claims Specialist, Miscellaneous Medical Facilities Professional Liability

Own and manage LTC Professional Liability Claims from first notice through resolution: investigate, analyze coverage, evaluate liability and damages, establish and adjust reserves, negotiate settlements and close files within authority. Perform advanced coverage analysis (duty to defend vs. indemnify, occurrence vs. claims-made, allocation, additional insured issues, contractual liability, tail exposures, endorsements) and prepare clear coverage opinions and reservation of rights/declination communications. Document claims thoroughly using Claims Management System and proactively diary follow-up actions and deadlines. Set indemnity and expense reserves within authority; escalate and recommend reserves for matters outside authority; review reserves regularly and justify reserve positions to management and auditors. Manage litigation: retain and oversee outside defense counsel with LTC expertise, control budgets and billing, direct discovery strategy, and evaluate mediation/arbitration/trial risk to optimize resolution. Coordinate clinical resources and expert consultants (nursing, pharmacy, infection control, medical specialists) for chart review, causation analysis and expert testimony. Interface with regulatory, compliance and risk management teams on CMS/state surveys, licensing investigations and mandatory reporting; incorporate regulatory developments into case strategy. Collaborate with underwriting, reinsurance and subrogation on allocation, ceded reporting and recovery opportunities. Identify and report claim trends, coverage exposures and policy issues to management and underwriting; contribute to playbooks, training and process improvements. Participate in mediations and arbitrations within settlement authority and support major loss response efforts. Maintain required adjuster licenses and adhere to company litigation and billing guidelines. Minimum 7 years of claims/legal experience with substantive, hands-on LTC Professional Liability claim handling; experience managing high-severity, multi-claimant or regulatory matters required. Demonstrated advanced knowledge of professional liability coverage interpretation and complex coverage issues. Strong litigation management experience, including selection and supervision of outside defense counsel, bill oversight and cost control. Practical understanding of clinical issues common to LTC (falls, pressure injuries, medication errors, infections/outbreaks, staffing/care plan issues) and relevant regulatory landscape. Proven analytical, negotiation and written/verbal communication skills; able to present complex clinical and coverage positions to counsel, underwriters and senior management. Bachelor's degree required, and advanced degree is a plus!