Claims Specialist

New Haven, CT
Oct 4, 2018

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Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
EEO/AA/Disability/Veteran
Summary:
Responsible for managing General Liability (GL) claims; claim investigation duties of other types of litigation including Professional Liability (PL) and Employment Liability (EPL) claims; monitoring compliance with certain litigation procedures and regulatory reporting requirements related to malpractice payments; administration of the YNHHS legal hold process; support for responding to subpoenas; insurance administration and risk mitigation projects as assigned.
Responsibilities:
  • 1. Professional liability and litigation program functions as assigned:
  • 1.1 Reconcile monthly financial reserve reports.
  • 1.2 Institutional Claims Committee meetings including, but not limited to, identification of reportable matters, preparation of commitee materials, and record keeping.
  • 1.3 Monitor compliance with certain claim handling requirements.
  • 1.4 Train and monitor litigation support staff to ensure smooth and efficient functioning.
  • 1.5 Assist with preparation of NPDB and other claims payment regulatory reports as needed, and monitor compliance with regulatory requirements.
  • 1.6 Respond to insurance and underwriting questions.
  • 1.7 Respond to subpoenas with assistance of counsel.
  • 1.8 Legal Hold duties.
  • 1.9 Claim audit support.
  • 1.10 Management of Evidence Sequestration Process.
  • 2. Claims investigation and adjusting duties as assigned:
  • 2.1 Identify and collect relevant personnel, medical, hopsital, and other records necessary to investigate asserted claims and forward them to counsel.
  • 2.2 Interview witnesses/insureds as directed.
  • 2.3 Schedule case meetings and depositions; participate in preparation meetings as requested.
  • 2.4 Preparation or assist in preparation of selected interrogatory and production responses; obtain signatures.
  • 2.5 Develop and document investigation plans in the context of the allegations and litigation management plan within required timeframes.
  • 2.6 Summarize relevant medical records in the context of the allegations.
  • 2.7 Assess or assist in assessing liability, damages and claim value.
  • 2.8 Develop or assist in developing case management plans.
  • 2.9 Establish or assist in establishing appropriate case reserves.
  • 2.10 Coverage identification.
  • 2.11 Negotiate and resolve claims within designated authority as assigned.
  • 2.12 Attend scheduled case status meeting with outside counsel.
  • 2.13 Vendor management, including but not limited to outside counsel selection, monitor budgets and review of vendor invoices within designated authority as assigned.
  • 2.14 Provide Hospital operational expertise to defense strategies and discovery requests.
  • 3. Risk mitigation functions as the bridge between Risk Management and Litigation Services including, but not limited to, the following:
  • 3.1 Risk mitigation functions as assigned through timely reporting of applicable events to MCIC; liaison between Risk Management and the disclosure project coordinator; tracking billing waivers; escalating risk potential across YNHHS as identified in claims; and escalating claims/litigation lessons learned or feedback from internal claims committee into risk management plan across YNHHS.
  • 3.2 Incorporate root cause analysis findings into claim defensibility analysis.
  • 3.3 Analysis and trending of claims for leadership
  • 4. Department projects and functions as assigned
    Other information:

    EDUCATION:

    Undergraduate degree or High School Diploma, plus formal paralegal and/or claims investigation/adjusting training and/or experience.

    EXPERIENCE:

    No less than five (5) years working as a claims investigator, claims adjuster or litigation paralegal. Experience in complex litigation is required, medical malpractice and/or general liability litigation experience is preferred. General knowledge of legal practice and procedures and various court systems is necessary. Experience in a healthcare setting with clinical experience is preferred.

    LICENSURE:

    CT claims adjusters'' license and/ or nursing degree is preferred.

    SPECIAL_SKILLS:

    Must have excellent communication skills, both verbal and written. Must demonstrate excellent organizational and problem solving skills. Must possess the ability to interact with all types and levels of personnel, and in stressful situations. Must be able to assist staff with triage and setting of priorities to ensure the smooth operation of the office and exceptional customer service are maintained. Must be able to coordinate several activities at once, quickly analyze and resolve specific problems, and cope with deadlines.

    Microsoft Office (Outlook, Word, Excel, PowerPoint), Adobe. Ability to learn LRSD document and claims management system.
    ACCOUNTABILITY:

    Accountable for managing workload of assigned matters within required processes and timelines. Participates in evaluation of office functions and suggests or makes changes to facilitate the process. Works cooperatively and in a coordinated fashion.

    Responsible for independently meeting deadlines and providing timely solutions to issues identified.
    COMPLEXITY:

    In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right
    thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic).

    Ability to juggle competing matters simultaneously.

    Process Oriented. Good at figuring out the processes necessary to get things done, knows how to organize people and activities, understands how to separate and combine tasks into efficient work flow, understands business needs and trends and can see opportunities for synergy and integration.

    Attention to Detail. Double-checks the accuracy of information and work product to provide accurate and consistent work. Provides information on a timely basis and in a usable form to others who need to act on it. Carefully monitors the details and quality of own and others'' work. Completes all work according to procedures and standards.

    Problem solving skills. Builds a logical approach to address problems or opportunities or manage the situation at hand by drawing on one''s knowledge and experience base, and calling on other references and resources as necessary. Thinks of several possible explanations or alternatives for a situation and anticipates potential obstacles and develops contingency plans to overcome them. Identifies the information needed to solve a problem effectively. Presents problem analysis and recommended solution to others rather than just identifying or describing the problem itself.

    Client Focus. Dedicated to meeting the expectations and requirements of internal and external clients. Act with the client in mind. Establish and maintain effective relationships with clients and gain their trust and respect.
    PHYSICAL_DEMAND:

    N/A

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    Job Info

    Job: 1834

    Department: HSC Legal
    Category: Legal - Compliance
    Status: Full Time
    Shift: DAYS
    Hours: 40.00