CLAIMS SPECIALIST II / SR. CLAIMS SPECIALIST

Cooperative of American Physicians, Inc.•Los Angeles, CA

93d

About The Position

Performs technical and administrative duties to manage assigned claim files. Participates in the continued training and supervision of Claims Specialist I’s. The role manages medical malpractice claims and increasingly complex cases with larger financial exposure under supervision and in compliance with applicable claims, defense attorney, and MPT guidelines. It also investigates and evaluates claims, supports litigation and resolution activities, maintains accurate claim records, and assists management with training and special projects.

Requirements

Bachelor’s degree from a four-year college or university.
Relevant legal and/or medical education background, or equivalent.
Minimum of three years of medical malpractice claims management experience and/or one year of CAP claims experience.
Valid California driver license.
Excellent demonstrated verbal and written communication skills.
Effective time management skills.
Ability to manage multiple priorities and deadlines.
Strong analytical skills.

Nice To Haves

Personal computer literacy is preferred.

Responsibilities

Manage medical malpractice claims, including assigning, directing, and controlling defense counsel under supervision and in compliance with the Claims Technical Manual, Defense Attorney Guidelines, and MPT Agreement.
Manage increasingly complex cases with larger financial exposure and review bills for reasonableness.
Investigate and evaluate claim files by meeting performance standards, interviewing members, reviewing medical records, corresponding with plaintiff attorneys, obtaining preliminary expert evaluations or opinions, and preparing interview summaries.
Prepare case evaluation reports for publication and presentation to the CRC and CSC.
Prepare case evaluation reports for discretionary authority on selected cases.
Manage and participate in litigation activity, including discovery plans, mediation, MSC, and negotiations, under supervision as necessary.
Monitor trials and arbitrations, provide daily progress reports, and support members and defense attorneys.
Prepare claim file resolution documentation.
Timely update the claims database.
Document important case developments under the chronology tab.
Code claims files and update them as relevant information becomes available.
Provide assistance to management on special projects as indicated.
Identify, investigate, and follow up on coverage issues.
Timely review and index documents in the On Base system.
Take Hotline calls as requested and as necessary, and prepare hotlines.
Attend staff and department meetings as indicated.
Assist management in training Claims Specialist I’s.
Perform other duties as necessary.