Manager, Claims Operations

Baptist Health•Homewood, AL

About The Position

Responsible for providing strategic leadership, oversight, and coordination of claims activities across a multi-hospital region within the health system, with a focus on medical professional and general liability claims. Serves as a key advisor to senior leadership, working collaboratively with clinical, operational, and legal teams to minimize claims exposure. Directs assigned staff and outside legal counsel, ensuring effective claims management. Serves as a source of guidance, support, and oversight to a team of Claims Adjusters.

Requirements

Bachelor’s degree in healthcare (preferred), business or closely related field.
Five (5) years of medical-legal or claims adjusting experience.
Clinical experience also preferred.

Responsibilities

Manages the development, coordination, and continuous improvement of the claims program, including regional strategies for claims handling, ensuring alignment with organizational objectives.
Oversees day-to-day operations of the claims program, providing operational leadership and direction to Claims Adjusters across assigned areas, while ensuring accountability and consistency in claims handling.
Supports departmental planning and goal execution by aligning claims management activities with organizational priorities and initiatives.
Provides operational leadership to enhance claims processing, minimizing loss exposure and contributing to the protection of organizational assets.
Analyzes claims data and trends to identify opportunities for risk management, quality, and patient safety improvements.
Develops and coordinates claims education programs to further reduce loss exposure.
Participates in internal claims team meetings, routine claims strategy meetings, and organizational meetings at regional and corporate levels.
Prepares and presents claims activity and initiatives to leadership, insurance underwriters, and organizational committees.
Prepares and maintains updated claims reports for leadership review.
Demonstrates subject matter expertise in claims handling.
Serves as an escalation point for complex claims issues, providing expert guidance and decision-making support to Claims Adjusters.
Serves as a regional expert and source of support across a multi-hospital assignment.
Manages assigned claims, with a focus on professional and general liability, but also including property, auto, and other lines.
Coordinates a complete investigation and evaluation of all assigned claims, providing oversight and direction to Claims Adjusters, and collaborating with claims leadership to develop effective strategy for resolution of each claim.
Participates in evaluating, setting, and adjusting reserves, in conjunction with claims leadership.
Utilizes claims management and loss reduction techniques in negotiating and settling claims within designated authority.
Handles mediations, as assigned by claims leadership and within designated authority.
Maintains, evaluates, and oversees management of claim files to ensure detailed documentation of all significant claims’ activity, including substantive communications with legal counsel and insurance contacts, analysis and evaluation of all witnesses, witness testimony, key defensibility issues, and decision-making for each claim.
Ensures that a trusting, liaison-type relationship is established between claims team members, outside legal counsel, and involved Baptist Health team members and physicians, from initiation of the claim through resolution.
Ensures that a robust claims investigation is completed on each claim, and that all claim activities are properly coordinated with assigned legal counsel, including comprehensive interpretation of medical records, retention of key experts, complete facilitation of discovery, in-depth and thorough research, as needed, and coordination of and attendance at witness interviews and depositions.
Fully participates in trial preparation and oversight, including focus groups, witness preparation, and development of trial exhibits.
Attends and oversees trial on all assigned claims and reports day-to-day findings and analysis to claims leadership.
Manages and oversees licensure investigations involving employed physicians and team members, in conjunction with assigned legal counsel.
Reviews all legal billing and claims expenses to ensure compliance with litigation plan and prepares and presents data to assist with departmental budget.
Maintains reasonably regular, punctual attendance consistent with Baptist Health policies, the ADA, FMLA and other federal, state and local standards.
Maintains compliance with all Baptist Health policies and procedures.