CLAIMS SPECIALIST II / SR. CLAIMS SPECIALIST

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

23h

About The Position

Performs technical and administrative duties to manage assigned claim files. Participates in the continued training and supervision of Claim Specialist I’s. Manages medical malpractice claims, including the assignment, direction and control of defense counsel, under supervision and in compliance with the Claims Technical Manual, the Defense Attorney Guidelines, and the MPT Agreement. Manages increasingly complex cases with larger financial exposure. Reviews all bills for reasonableness. Investigates and evaluates claim files including complying with the standards of performance, interviewing members, reviewing medical records, corresponding with plaintiff attorneys, obtaining preliminary expert evaluation/opinions, and preparing interview summaries. Prepares case evaluation reports for publication and presentation to the CRC and CSC. Prepares case evaluation reports for discretionary authority on selected cases. Manages and participates in all litigation activity, including discovery plan, mediation, MSC, and negotiation under supervision, as necessary. Monitors trials and arbitrations including daily progress reports, providing member and defense attorney with support. Prepares claim file resolution documentation. Timely updates the claims database. Documents all important case developments under the chronology tab. Codes the claims file and updates as relevant information is available. Provides assistance to management as indicated on special projects. Identifies, investigates and follows-up on coverage issues. Timely reviews and indexes documents to the On Base system. Takes Hotline calls as requested and as necessary and prepares hotlines. Attends staff and department meetings as indicated. Assists management in training of Claims Specialist I.

Requirements

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

Responsibilities

Manage medical malpractice claims, including the assignment, direction and control of defense counsel, under supervision and in compliance with the Claims Technical Manual, the Defense Attorney Guidelines, and the MPT Agreement.
Manage increasingly complex cases with larger financial exposure.
Review all bills for reasonableness.
Investigate and evaluate claim files including complying with the standards of performance, interviewing members, reviewing medical records, corresponding with plaintiff attorneys, obtaining preliminary expert evaluation/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 all litigation activity, including discovery plan, mediation, MSC, and negotiation under supervision, as necessary.
Monitor trials and arbitrations including daily progress reports, providing member and defense attorney with support.
Prepare claim file resolution documentation.
Timely update the claims database.
Document all important case developments under the chronology tab.
Code the claims file and update as relevant information is available.
Provide assistance to management as indicated on special project.
Identify, investigate and follow-up on coverage issues.
Timely review and index documents to 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 of Claims Specialist I.
Perform other duties as necessary.