Senior Claims Examiner

University of Florida•Gainesville, FL

About The Position

The Senior Claims Examiner is responsible for the intake, processing, and disposition of all incidents reported to the SIP. This role involves establishing incident reporting procedures, reviewing and evaluating incidents for improvement opportunities and potential claims, and ensuring accurate recording in the Claims database. The incumbent will conduct interviews, review records, and analyze information to determine the chronology of events and outcomes of incidents. They will also notify appropriate administration of significant incidents for review and reporting. Daily contact will be with faculty, staff, and administrators of various UF colleges, Shands facilities, and other Florida medical colleges. The position also involves identifying, investigating, analyzing, and evaluating medical, legal, and fiscal issues related to covered claims against SIP participants. This includes conducting factual investigations, evaluating claims for negligence, causation, and damages, presenting claims summaries, making reserve recommendations, and advising the SIP council and its Claims and Litigation Committee. Additionally, the Senior Claims Examiner will coordinate, manage, and resolve all covered claims without Notice of Intent, including negotiating with claimants, managing claim denials, and collaborating with litigation staff. The role also focuses on identifying risk factors contributing to claims and suits, coordinating file reviews for loss prevention activities, and collaborating with SIP Loss Prevention staff. This includes recommending activities to mitigate risks, providing advice on patient care liabilities, and conducting in-service education programs. The Senior Claims Examiner will also coordinate with SIP's Loss Prevention staff to mitigate risk factors, ensure appropriate referral of incident reports, and provide advice on risk management protocols. Attendance at Morbidity and Mortality Conferences, Quality Management Committees, and Code 15 Committee proceedings, as well as participation in Root Cause Analysis Meetings, is expected. Travel to out-of-town insured facilities for investigations and meetings is also required. The position provides investigative and administrative management support for healthcare providers facing administrative proceedings related to their medical licenses and facilitates the procurement of legal counsel. Services described may be provided on behalf of other SIPs or similar programs. Other duties as assigned include preparing witnesses for unsworn statements and representing covered entities at unsworn statements and depositions if licensed to practice law in Florida, and performing legal work such as preparing memos of law and conducting legal research if an attorney.

Requirements

Bachelor's degree in an appropriate area and six years of relevant experience; or an equivalent combination of education and experience.

Nice To Haves

Knowledge of health care systems and medical-legal techniques desired.
Ability to perform under great pressure in a multi-tasking environment.
Excellent oral and written communication skills.
Good native intelligence.
Ability to interact with individuals of all social and economic backgrounds.
Licensed to practice law in the State of Florida (for specific deposition/legal work).

Responsibilities

Intake, process, and dispose of all incidents reported and/or referred to the SIP.
Establish incident reporting procedures to be followed by the various units of the HSC and other SIP participants.
Ensure all reported incidents are reviewed and evaluated for patient care and health care delivery improvement opportunities and for potential claims falling under the purview of the SIP.
Be available to take incident reports, ensuring that reported incidents are promptly and accurately recorded in the Claims database.
Perform all interviews, records reviews, and information analysis necessary to determine the chronology of events and resulting outcomes of an incident.
Ensure that appropriate administration at SIP is timely notified of significant incidents.
Identify, investigate, analyze, and evaluate the medical, legal, and fiscal issues related to covered claims (potential or asserted) against participants of the SIP.
Conduct a full factual investigation of assigned claim files.
Evaluate claims in terms of negligence, causation, and compensable damages.
Present initial claims summaries to SIP internal committees.
Make indemnity and allocated loss expense reserve recommendations pursuant to established protocols.
Serve as advisor to and investigator for the SIP council and its Claims and Litigation Committee.
Provide assistance as required in fulfilling SIP administrative responsibilities, including the presentation of claims summaries and related reports.
Coordinate, manage, and resolve all covered claims without Notice of Intent, potential or asserted, against SIP participants.
Negotiate directly with claimants to resolve meritorious matters without the necessity of litigation.
Manage the denial of claims without merit up to Notice of Intent.
Collaborate with assigned Litigation staff for transition of claims that receive legal interest.
Identify risk factors that cause or contribute to claims and suits.
Coordinate and ensure that assigned files are reviewed and analyzed for potential loss prevention activities.
Ensure that assigned files contain appropriate documentation pertaining to loss prevention and risk reduction initiatives associated with the claim.
Collaborate directly with the SIP Loss Prevention staff to identify potential risks and opportunities for loss reduction.
Recommend activities to mitigate or remove identified risk factors.
Assist in follow-up on loss prevention programs.
Provide advice and assistance on an immediate access basis regarding patient care liabilities and protocols related to loss prevention.
Conduct in-service education programs, seminars, and topical presentations for faculty physicians, residents, nurses, or other healthcare providers.
Develop loss prevention awareness through regular interactions with the healthcare providers.
Demonstrate the benefits of established loss prevention programs and successful effort resulting from the proactive management of potential risks.
Ensure the appropriate referral to the Associate Director for Risk Management and Loss Prevention of incident reports involving patient care and health care delivery improvement, or statutory or regulatory reporting.
Assist in the implementation of medical/legal professional liability risk management functions performed by the SIP in furtherance of SIP’s contractual risk management responsibilities.
Provide advice and assistance on an immediate access basis regarding patient care liabilities and protocols related to risk management.
Attend Morbidity and Mortality Conferences, Quality Management Committees, and Code 15 Committee proceedings (as assigned).
Participate in Root Cause Analysis Meetings.
Travel to out-of-town insured facilities and investigate incidents and meet with involved healthcare providers.
Provide investigative and administrative management in support of healthcare providers subjected to administrative proceedings related to their medical license.
Facilitate the procurement of legal counsel for these providers.
Provide all services described within this position description on behalf of the other SIPs or other similar programs, while the other SIPs or other similar programs’ claims and litigation processes are managed by the SIP.
Prepare witnesses employed or formerly employed by covered entities for unsworn statements in pre-suit discovery.
Represent covered entities at unsworn statements and depositions, in those situations and circumstances where prior approval has been obtained from the Claims Officer, Claims and Litigation (if licensed to practice law in the State of Florida).
Perform a variety of legal work, including preparing memos of law, legal responses, and witnesses before trial; conduct legal research (if attorney).