(REMOTE) Claims Specialist

Trinity Health•Livonia, MI

2d•Remote

About The Position

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.

Requirements

Knowledge of professional and general liability and employment practices liability claims management normally acquired through completion of a Bachelor's degree.
Experience as a liability claims professional adjuster or hospital risk manager, or an equivalent combination of education and experience.
Working knowledge of medical and/or employment law terminology.
Strong analytical skills.
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.
Ability to meet deadlines and respond to shifting priorities.
Comfort operating in a collaborative, shared leadership environment.
A personal presence 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.

Nice To Haves

A clinical health care degree is preferred.
Advanced knowledge and working relationships in risk management, quality management and improvement is helpful.

Responsibilities

Investigating, evaluating and resolving Professional Liability (HPL), General Liability (GL), and Employment Practices Liability (EPL) claims.
Formulating and implementing thorough investigation plans for each claim.
Evaluating claims with respect to standard of care, liability, causation, and damages.
Determining the value of the claim, considering witness credibility and expert opinions.
Setting appropriate indemnity and expense reserves in a timely manner.
Establishing, facilitating, and communicating claim resolution strategies in conjunction with defense counsel and management.
Obtaining settlement authority as established by policy.
Independently negotiating or directing the negotiation of claims/lawsuits to resolution within delegated authority limits.
Notifying excess insurers of selected claims and providing file updates.
Maintaining a diary system to monitor all open claims and updating claim files per documentation guidelines.
Presenting claim information at internal claim reviews.
Representing the facility and/or Trinity Health at case evaluations, settlement conferences, mediations, and trials.
Retaining approved defense counsel and directing their work.
Reviewing and responding to attorney reports and recommendations, and approving defense counsel fees and litigation expenses.
Monitoring compliance with Medicare Secondary Payer requirements.
Identifying loss control issues and making recommendations.
Documenting risk modification and risk reduction strategies.
Collaborating with loss control directors to identify risk management trends, issues, and opportunities.
Adhering to corporate policy and procedures.
Maintaining a working knowledge of applicable laws, regulations, and the Trinity Health Integrity and Compliance Program and Code of Conduct.