Senior Claims Examiner - Gainesville or Jacksonville

University of Florida•Gainesville, FL

20h

About The Position

The Senior Claims Examiner intakes, processes, investigates, evaluates, manages, and resolves incidents and covered claims—potential or asserted—against participants in the SIP. The role establishes incident-reporting procedures for HSC units and other SIP participants under Rule 6C-10.001, reviews reported incidents for patient-care and health-care-delivery improvement opportunities and potential claims, and ensures timely and accurate recording and notification of significant incidents. The examiner conducts interviews, records reviews, and analysis to establish incident timelines and outcomes, and works regularly with faculty, staff, and administrators across participating universities, colleges, hospitals, and affiliated facilities throughout Florida. The position investigates the medical, legal, and fiscal issues associated with claims, including assessing negligence, causation, and compensable damages; presenting claim summaries to internal committees; and recommending indemnity and allocated loss expense reserves under established protocols. It manages assigned claims through denial, settlement, or defense, including negotiating with claimants on meritorious matters and coordinating with litigation staff when claims receive legal interest. It also identifies claim-related risk factors, coordinates loss-prevention and risk-reduction activities, offers guidance on patient-care liabilities and protocols, and may deliver educational programs and presentations to health-care providers. The examiner coordinates referrals for patient-care and health-care-delivery improvement or statutory and regulatory reporting; attends assigned quality and safety proceedings and participates in Root Cause Analysis meetings; and travels to insured facilities to investigate incidents and meet with providers. The position also supports providers involved in administrative proceedings related to their medical licenses and helps procure legal counsel. When authorized and, where applicable, licensed to practice law in Florida, the examiner may prepare and represent witnesses at unsworn statements and depositions and perform legal work such as legal research, memoranda, responses, and witness preparation. The role may also provide services for other SIPs or similar programs and perform additional assigned duties.

Requirements

Bachelor's degree in an appropriate area and six years of relevant experience, or an equivalent combination of education and experience.
Ability to investigate and evaluate claims, including factual issues, negligence, causation, and compensable damages.
Excellent oral and written communication skills.
Ability to interact with individuals from a range of social and economic backgrounds.

Nice To Haves

Knowledge of health-care systems.
Knowledge of medical-legal techniques.
Ability to perform under great pressure in a multitasking environment.
Good native intelligence.
Florida law license for legal work or witness representation where applicable.

Responsibilities

Intake, process, and dispose of incidents reported or referred to the SIP.
Establish incident-reporting procedures for HSC units and other SIP participants in accordance with Rule 6C-10.001.
Review reported incidents for patient-care and health-care-delivery improvement opportunities and potential claims; take incident reports, document them promptly and accurately in the Claims database, and conduct interviews, records reviews, and analysis to determine chronology and outcomes.
Notify appropriate SIP administration of significant incidents in a timely manner for review by the Director and, when appropriate, notification of affected SIP participants.
Identify, investigate, analyze, and evaluate medical, legal, and fiscal issues related to potential or asserted covered claims against SIP participants.
Conduct factual investigations; evaluate negligence, causation, and compensable damages; present initial claim summaries to internal committees; and recommend indemnity and allocated loss expense reserves under established protocols.
Advise and investigate for the SIP council and its Claims and Litigation Committee, and assist with SIP administrative responsibilities, including preparing claim summaries and related reports.
Manage and resolve assigned covered claims without Notice of Intent, including denial, settlement, or defense; negotiate with claimants to resolve meritorious matters, manage denial of claims without merit up to Notice of Intent, and coordinate transition of claims receiving legal interest with litigation staff.
Identify claim-related risk factors and coordinate file reviews and documentation of loss-prevention and risk-reduction initiatives.
Work with SIP Loss Prevention staff to identify risks and loss-reduction opportunities, recommend mitigation activities, and assist with follow-up on loss-prevention programs.
Provide immediate-access advice and assistance regarding patient-care liabilities and protocols related to loss prevention and risk management.
Conduct in-service education, seminars, and topical presentations for physicians, residents, nurses, and other health-care providers; promote loss-prevention awareness and communicate the benefits of established programs.
Refer incident reports involving patient care, health-care-delivery improvement, or statutory or regulatory reporting to the Associate Director for Risk Management and Loss Prevention as appropriate.
Attend assigned Morbidity and Mortality Conferences, Quality Management Committees, and Code 15 Committee proceedings, and participate in Root Cause Analysis meetings.
Travel to out-of-town insured facilities to investigate incidents and meet with involved health-care providers.
Provide investigative and administrative support to health-care providers subjected to administrative proceedings related to their medical licenses and facilitate procurement of legal counsel.
Provide services on behalf of other SIPs or similar programs whose claims and litigation processes are managed by the SIP.
When authorized, prepare witnesses employed or formerly employed by covered entities for unsworn statements in pre-suit discovery and represent covered entities at unsworn statements and depositions, if licensed to practice law in Florida.
If an attorney, perform legal work including legal research, preparing memoranda of law and legal responses, and preparing witnesses before trial.
Perform other assigned duties and functions.