Claims Mgr

Major Responsibilities:
Leads, manages and maintains responsibility in the claims and strategic management of professional and general liability claims and litigation under the umbrella of AISPC and the Claims Management program.

Identifies through complex analysis the appropriate insurance venue and provides professional claims resolutions and judgments when required and provides direction to retained outside defense counsel through the analysis of claims management to improve the quality of patient care, reduce risk and minimize or eliminate potential and actual financial, physical and reputational losses in compliance with AAH policy.

Utilizes a proactive risk management approach that relates to an enterprise scope of practice. Establishes relationships with site executive and medical staff leadership to identify and facilitate development and resolution of system and site risk identification and reduction measures. Oversees the development of site risk management programs, ensuring standard assessment and measures. Supports appropriate risk management coverage within site.

Lead and oversee the process for the establishment of sound, timely and accurate indemnity and expense reserves. This includes authority over the resolution of claims litigated cases pursuant to department guidelines and authority levels established by Risk Management procedures and the system Financial Control Policy; establish and ensure compliance to standards for all indemnity and expense reserves; oversee the creation of claims and litigation reports for site and system stakeholders including EMT and senior leadership; oversee the creation and review of all department guidelines, policies and procedures, processes and management structure for handling liability matters.

Addresses health outcomes, risk identification, loss prevention, and claims management to improve the quality of patient care; prevent, mitigate and/or reduce risk of potential and actual financial, physical and reputational loss at assigned sites. Participates in site health outcomes goals and strategic plan development, implementation and measurement including provision of data and recommendation within the site. Participates in site level safety huddles; participate in weekly risk huddles. Identifies, in conjunction with site and other departments, high risk areas requiring proactive risk assessments.

Provides claims management direction and manages assigned sites on all aspects of litigation, including discovery, system wide and site policies and procedures that establish standards and impact claims, risk management and general/professional liability exposures. Analyzes and provides formal reports to the sites for claims activities for system executive quarterly report card submission. Analyzes and presents the Risk Management Annual Report summary and analysis to site executives, leaders, medical staff, clinical divisions and governing council. Reviews, analyzes, and develops improvement actions based on claims loss runs.

Attends and monitors all pre-trials and trials. Acts as a representative at court during pretrial and trial situations as needed and evaluates the need to designate site risk staff to attend trial as the representative of the hospital. Manages any negotiation and settlements any asserted claims according to the Advocate Financial Approval Policy, the requirements under CMS section 111- Mandatory Insurer Reporting, and Advocate claims management guidelines.

Manages the processes at the sites for handling of defense counsel requests, collection of information necessary during the discovery process and to prepare for the defense of claims and lawsuits. Reviews all interrogatories, production requests and other documents, prior to signature sign off by the site.

Reviews all site’s quarterly loss runs for significant trends, claims analysis, and reporting to site matrix report. Participates in regular conference calls with Site Risk Management Departments for review of potential and current claims. Keeps management informed of site-based issues; coordinate communication to site from system.

Works collaboratively with Legal and Compliance on site issues, contracts, regulatory and accreditation issues, operational and policy issues, governmental, litigation and other relevant issues.

Education/Experience Required:
License/Registration/Certification: None

Knowledge, Skills & Abilities Required:
• Strong decision-making and critical thinking skills.

• Excellent communication skills (oral and written, group and one-on-one).

• Knowledge of statistical methods, data analysis and presentation.

• Expert in Risk Management, Litigation and Insurance fields

• Proficient in Microsoft Office (Excel, Word, PowerPoint, Access) or similar products.

Level of Education: Bachelor's Degree in Law; Health Law Years of Experience: Requires 7 years of experience in claims and risk management experience with hospitals, healthcare systems or physician insurance companies or related medical industry field.

Physical Requirements and Working Conditions:

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.