(REMOTE) Claims Specialist
About The Position
The Claims Specialist investigates, evaluates, and resolves assigned Professional Liability (HPL), General Liability (GL), and Employment Practices Liability (EPL) claims. The role formulates investigation plans; evaluates standard of care, liability, causation, damages, witness credibility, and expert opinions; determines claim value; and establishes appropriate indemnity and expense reserves. In coordination with defense counsel and the (Senior) Area Claims Manager when appropriate, the Specialist develops and communicates resolution strategies, obtains settlement authority, and negotiates or directs negotiations within delegated authority. The Specialist also manages excess-insurer notifications, claim-file documentation and monitoring, internal claim reviews, and representation at case evaluations, settlement conferences, facilitations, mediation, and trial. The role retains and supervises approved outside defense counsel, reviews counsel reports and recommendations, approves fees and litigation expenses, and keeps the (Senior) Area Claims Manager apprised of developments. It monitors compliance with Medicare Secondary Payer requirements, identifies loss-control issues, documents risk-reduction strategies, and collaborates with loss-control directors on risk-management trends and opportunities. The Claims Specialist adheres to Insurance and Risk Management Services and Trinity Health policies and procedures, and maintains knowledge of applicable laws, regulations, compliance requirements, and the Code of Conduct. This position operates in a typical, well-lit, temperature-controlled office environment free from hazards and barriers, with travel to Trinity Health sites and other locations expected up to 50% of the time. The Specialist must adapt to changing priorities, work under pressure, and perform moderate physical activity, including lifting and bending. The hourly pay range is $37.07–$55.60.
Requirements
- Knowledge of professional and general liability and employment practices liability claims management, normally acquired through a bachelor's degree and 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 orally and in writing with all levels of the organization.
- Initiative and ability to handle responsibility independently.
- Ability to meet deadlines and respond to shifting priorities.
- Comfort operating in a collaborative, shared-leadership environment.
- Honesty, integrity, caring, and ability to inspire and motivate others in support of Trinity Health’s philosophy, mission, vision, goals, and values.
- Ability to adapt to frequently changing work priorities and work under pressure.
- Ability to perform moderate physical activity, lifting, and bending.
- Ability to travel to Trinity Health sites and other related locations up to 50% of the time.
Nice To Haves
- A clinical health care degree is preferred.
- Advanced knowledge and working relationships in risk management, quality management, and improvement are helpful.
Responsibilities
- Investigate, evaluate, and resolve assigned Professional Liability (HPL), General Liability (GL), and Employment Practices Liability (EPL) claims.
- Formulate and implement a thorough investigation plan for each assigned claim.
- Evaluate standard of care, liability, causation, damages, witness credibility, and expert opinions; determine claim value.
- Set appropriate indemnity and expense reserves in a timely manner.
- Establish and communicate claim resolution strategies in conjunction with defense counsel and the (Senior) Area Claims Manager when appropriate.
- Obtain settlement authority according to policy and negotiate or direct negotiations within delegated authority.
- Notify excess insurers of selected claims and provide file updates according to reporting guidelines.
- Maintain a diary system for open claims and update claim files according to documentation guidelines.
- Present claim information at internal claim reviews.
- Represent the facility and/or Trinity Health at case evaluations, settlement conferences, facilitations, mediation, and trial.
- Retain approved defense counsel on a per-claim basis and direct and supervise counsel under the litigation protocol.
- Review and respond to attorney reports and recommendations as appropriate; review and approve defense counsel fees and litigation expenses.
- Keep the (Senior) Area Claims Manager apprised of case developments as appropriate.
- Monitor compliance with Medicare Secondary Payer requirements, including CMS inquiry responses, Stars files, lien information, and appropriate MSP language in responses and settlement documents.
- Identify loss-control issues and make recommendations; document risk-modification and risk-reduction strategies in claim files and STARS.
- Collaborate with loss-control directors to identify risk-management trends, issues, and opportunities.
- Adhere to Insurance and Risk Management Services and Trinity Health policies and procedures, applicable laws and regulations, the Integrity and Compliance Program, and the Code of Conduct.
