Senior Claims Examiner - Gainesville or Jacksonville

University of Florida•Gainesville, FL

About The Position

The Senior Claims Examiner intakes, processes, and disposes of incidents reported or referred to the SIP. The role establishes incident-reporting procedures for HSC units and SIP participants, ensures incidents are promptly and accurately documented, and reviews them for patient-care and healthcare-delivery improvement opportunities and potential claims. The examiner conducts interviews, records reviews, and analyses to establish incident chronology and outcomes, and promptly notifies appropriate SIP administration of significant incidents for review and, when appropriate, notification of affected participants. The position identifies, investigates, analyzes, and evaluates medical, legal, and fiscal issues related to potential or asserted claims against SIP participants. Responsibilities include conducting factual investigations, assessing negligence, causation, and compensable damages, preparing initial claim summaries for internal committees, recommending indemnity and allocated-loss-expense reserves, advising and investigating for the SIP Council and its Claims and Litigation Committee, and assisting with SIP administrative responsibilities. The examiner manages and resolves assigned covered claims that have not received a Notice of Intent, including negotiating settlements, denying claims without merit up to Notice of Intent, and coordinating with litigation staff when a claim receives legal interest. The role also identifies claim-related risk factors, collaborates with loss-prevention staff, recommends risk-reduction activities, supports follow-up on programs, provides advice on patient-care liabilities and protocols, and delivers education and presentations to healthcare providers. The position coordinates referrals to the Associate Director for Risk Management and Loss Prevention; attends assigned clinical and quality committees and participates in Root Cause Analysis Meetings. Travel to insured facilities for investigations and meetings with healthcare providers is required. The examiner also provides investigative and administrative support to healthcare providers facing administrative proceedings related to their medical licenses, including facilitating access to legal counsel. The role may provide services on behalf of other SIPs or similar programs. Other assigned duties may include preparing witnesses for unsworn pre-suit statements and representing covered entities at statements and depositions, with prior approval from the Claims Officer, Claims and Litigation, if licensed to practice law in Florida. If an attorney, the incumbent may also perform legal work such as preparing legal memoranda and responses, preparing witnesses before trial, and conducting legal research.

Requirements

Bachelor's degree in an appropriate area and six years of relevant experience, or an equivalent combination of education and experience.
Upload a cover letter and resume with the application.

Nice To Haves

Knowledge of healthcare systems and medical-legal techniques.
Ability to perform under great pressure in a multitasking environment.
Excellent oral and written communication skills.
Good native intelligence.
Ability to interact with individuals of all social and economic backgrounds.
Florida law license for the conditional duties involving witness representation and legal work.

Responsibilities

Intake, process, and dispose of incidents reported or referred to the SIP.
Establish incident-reporting procedures for HSC units and other SIP participants.
Ensure reported incidents are accurately recorded, reviewed, and evaluated for patient-care and healthcare-delivery improvement opportunities and potential SIP claims.
Conduct interviews, records reviews, and information analyses to determine incident chronology and outcomes.
Notify appropriate SIP administration of significant incidents in a timely manner for review and, when appropriate, reporting to affected participants.
Identify, investigate, analyze, and evaluate medical, legal, and fiscal issues related to potential or asserted covered claims.
Conduct factual investigations of assigned claim files and evaluate negligence, causation, and compensable damages.
Present initial claim summaries to SIP internal committees and recommend indemnity and allocated-loss-expense reserves under established protocols.
Serve as advisor to and investigator for the SIP Council and its Claims and Litigation Committee, and assist with SIP administrative responsibilities.
Manage and resolve assigned covered claims without Notice of Intent, including denial, settlement, or defense.
Negotiate directly with claimants to resolve meritorious matters without litigation and manage denials of claims without merit up to Notice of Intent.
Coordinate with assigned litigation staff when claims receive legal interest.
Identify claim and suit risk factors and ensure assigned files are reviewed for loss-prevention opportunities and appropriately documented.
Collaborate with Loss Prevention staff to identify risks, recommend mitigation activities, and assist with follow-up on loss-prevention programs.
Provide immediate-access advice and assistance concerning patient-care liabilities, protocols, and risk management.
Conduct in-service education programs, seminars, and topical presentations for healthcare providers, and promote loss-prevention awareness through regular interaction.
Refer appropriate incident reports to the Associate Director for Risk Management and Loss Prevention and assist with SIP medical/legal professional liability risk-management functions.
Attend assigned Morbidity and Mortality Conferences, Quality Management Committees, and Code 15 Committee proceedings, and participate in Root Cause Analysis Meetings.
Travel to insured facilities to investigate incidents and meet with involved healthcare providers.
Provide investigative and administrative support to healthcare providers subject to administrative proceedings related to their medical licenses, and facilitate procurement of legal counsel.
Provide services on behalf of other SIPs or similar programs when required.
Perform other assigned duties.
With prior approval from the Claims Officer, Claims and Litigation, prepare witnesses employed or formerly employed by covered entities for unsworn pre-suit statements and represent covered entities at statements and depositions, if licensed to practice law in Florida.
If an attorney, perform legal work including preparing legal memoranda and responses, preparing witnesses before trial, and conducting legal research.