Claims Specialist

Employment Type:

Full time

Shift:

Day Shift

Description:

POSITION PURPOSE
Responsible for investigating, evaluating and resolving Professional Liability (HPL), General Liability (GL), and Employment Practices Liability (EPL) claims assigned by the (Senior) Area Claims Manager (SCAM).

• Knows, understands, incorporates and demonstrates the Trinity Health mission, vision, and values in behaviors, practices and decisions.

• Formulates and implements thorough investigation plan for each claim assigned. Evaluates claim with respect to standard of care, liability, causation, and damages. Considers witness credibility and expert opinions and determines the value of the claim. Timely sets appropriate indemnity and expense reserves.

• In conjunction with defense counsel, and (S)ACM when appropriate, establishes a claim resolution strategy, facilitates and communicates same. Obtains settlement authority as established by policy. Within delegated authority limits, independently negotiates or directs the negotiation of the claims/lawsuit to resolution.

• Notifies excess insurer of selected claims according to established criteria and provides file updates pursuant to reporting guidelines.

• Maintains a diary system to monitor all open claims. Updates claim files per documentation guidelines.

• Presents claim information at internal claim reviews.

• Represents facility and/or Trinity Health at case evaluations, settlement conferences, facilitations, mediation, and trial.

• Retains approved defense counsel on a per claim basis. Directs and supervises the work of outside defense counsel pursuant to the litigation protocol. Reviews and responds to attorney reports and recommendations as appropriate. Reviews and approves the defense counsel fee and litigation expenses.

• Keeps (S)ACM apprised of case developments as appropriate.

• Responsible for monitoring compliance with Medicare Secondary Payer requirements including recording CMS responses to inquiry into Stars, monitoring appropriate Stars files for continued compliance with regulations, obtaining and monitoring lien information, and reviewing responses and settlement documents for appropriate MSP language.

• Identifies loss control issues and makes recommendations as appropriate. Documents risk modification and risk reduction strategies in file and in STARS. Works collaboratively with loss control directors to identify risk management trends, issues and opportunities.

• Adheres to Insurance and Risk Management Services (IRMS) and Trinity Health corporate policy and procedures.

• Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

MINIMUM QUALIFICATIONS

• Must possess knowledge of professional and general liability and employment practices liability claims management that is normally acquired through completion of a Bachelor's degree and experience as a liability claims professional adjuster or hospital risk manager, or an equivalent combination of education and experience. A clinical health care degree is preferred.

• Advanced knowledge and working relationships in risk management, quality management and improvement is helpful.

• Working knowledge of medical and/or employment law terminology is required.

• Strong analytical skills are necessary as well as the ability to organize and communicate information both orally and in writing with all levels of the organization.

• Initiative and the ability to handle responsibility independently are necessary.

• Ability to meet deadlines and respond to shifting priorities is necessary. Must be comfortable operating in a collaborative, shared leadership environment.

• A personal presence which is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health is essential.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

• This position operates in a typical office environment. The area is well-lit, temperature controlled and free from hazards and barriers.

• Travel to the various Trinity Health sites up to 50% of the time. (Travel to meet with other related parties at various locations is expected).

• Must be able to adapt to frequently changing work priorities as well as work under pressure.

• Must be able to perform moderate physical activity, lifting and bending.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

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