• Responsible for processing health insurance claims submitted via paper or electronically by providers and members • Validates health insurance claims with an understanding of health insurance cost sharing, limitations, and exclusions • Reviews claims for completeness and accuracy • Releases health insurance claims for payment according to the defined workflows • Works assigned pend and error reports • Determines benefit level to be paid according to the summary plan language • Responds promptly to requests for information from other Sanford Health Plan departments • Refers complex claims to Senior and/or Lead Claims Representatives.

Role Description The Senior Claims Specialist within GB Specialty is responsible for managing moderately complex Healthcare Professional Liability claims. This role manages the full claim life cycle, including coverage analysis, investigation, evaluation, and resolution, while ensuring claims are handled in accordance with client expectations, policy obligations, and regulatory requirements. - Analyzes coverage and settles moderately complex claims in Healthcare Professional Liability. - Generally, incumbent does not work on workers’ compensation claims. - Able to manage the full-life cycle of all assigned claims files. - Analyzes coverage and determines defense obligations. - Under minimal supervision, conducts thorough analysis and investigations necessary to determine claims exposure and recommend appropriate settlement strategies and action plans. - Creates reservation of rights and coverage denial letters. - Negotiates settlements with clients, client attorneys, and Public Adjusters. - Interacts extensively with various parties involved in the claims process, and may recommend retaining the advice of outside experts as necessary. - Prepares reserve and settlement authority requests for client and carrier approval. - May act as a client advocate with carriers to ensure proper claims handling, including any necessary scoping, estimating, and addressing of coverage. - Has a solid understanding of claims processing and the insurance brokerage business. - Has a basic understanding of the terminology and case law associated with medicine professional liability claims. - Handles claims consistent with clients’ and corporate policies, procedures and best practices and in accordance with statutory, regulatory, and ethical requirements. - Incumbents at this level should be able to work at full caseload capacity. Qualifications - Bachelor's Degree and 5+ years related claims experience required. - Prior experience working within the applicable specialty claims area or demonstrated ability to handle unique/challenging claims issues. - Appropriately licensed and/or certified in all states in which claims are being handled or able to obtain the licenses/certification per local requirements. - Knowledge of accepted industry standards and practices. - Computer experience with related claims and business software. Requirements - JD Highly Preferred. - Licensed Attorney highly preferred. - 2+ years of prior experience adjusting claims in Healthcare professional Liability. Benefits - Medical/dental/vision plans, which start from day one! - Life and accident insurance. - 401(K) and Roth options. - Tax-advantaged accounts (HSA, FSA). - Educational expense reimbursement. - Paid parental leave. - Digital mental health services (Talkspace). - Flexible work hours (availability varies by office and job function). - Training programs. - Gallagher Thrive program – elevating your health through challenges, workshops and digital fitness programs for your overall wellbeing. - Charitable matching gift program. - And more...

Role Description The Senior Claims Specialist within GB Specialty is responsible for managing moderately complex Liability claims. This role manages the full claim life cycle, including coverage analysis, investigation, evaluation, and resolution, while ensuring claims are handled in accordance with client expectations, policy obligations, and regulatory requirements. - Analyzes coverage and settles moderately complex Liability claims. - Generally, incumbent does not work on workers’ compensation claims. - Able to manage the full-life cycle of all assigned claims files. - Analyzes coverage and determines defense obligations. - Under minimal supervision, conducts thorough analysis and investigations necessary to determine claims exposure and recommend appropriate settlement strategies and action plans. - Creates reservation of rights and coverage denial letters. - Negotiates settlements with clients, client attorneys, and Public Adjusters. - Interacts extensively with various parties involved in the claims process, and may recommend retaining the advice of outside experts as necessary. - Prepares reserve and settlement authority requests for client and carrier approval. - May act as a client advocate with carriers to ensure proper claims handling, including any necessary scoping, estimating, and addressing of coverage. - Has a solid understanding of claims processing and the insurance brokerage business. - Has a basic understanding of the terminology and case law associated with professional liability claims. - Handles claims consistent with clients’ and corporate policies, procedures and best practices and in accordance with statutory, regulatory, and ethical requirements. - Incumbents at this level should be able to work at full caseload capacity. Qualifications - High school diploma and 5 years related claims experience required. - Prior experience working within the applicable specialty claims area or demonstrated ability to handle unique/challenging claims issues. - Appropriately licensed and/or certified in all states in which claims are being handled or able to obtain the licenses/certification per local requirements. - Knowledge of accepted industry standards and practices. - Computer experience with related claims and business software. - Bachelor's Degree preferred. - Ten or more years of Liability claims adjusting experience. - Law Degree (JD) highly preferred. Requirements - Claims Background: Product, Construction (CD and GL), Environmental Liability - Complex Coverage. - Jurisdictional Experience: Open to any. - Active Adjusters' licenses: must be willing to obtain all licenses stated by manager within specified timeframe. Benefits - Medical/dental/vision plans, which start from day one! - Life and accident insurance. - 401(K) and Roth options. - Tax-advantaged accounts (HSA, FSA). - Educational expense reimbursement. - Paid parental leave. - Digital mental health services (Talkspace). - Flexible work hours (availability varies by office and job function). - Training programs. - Gallagher Thrive program – elevating your health through challenges, workshops and digital fitness programs for your overall wellbeing. - Charitable matching gift program. - And more...

• Receive, review, and analyze incoming insurance claims • Investigate claim details, including policy coverage, liability, and damage assessment • Communicate effectively with policyholders, agents, adjusters, and other relevant parties • Negotiate and settle claims within established authority limits • Maintain accurate and thorough claim records • Identify and report potential fraudulent claims • Collaborate with underwriting and legal departments on complex claims • Prepare and present claim reports and analyses to management