Medical Malpractice Claims Examiner
Position is responsible for the investigation, evaluation, adjudication and resolution of claims and lawsuits presented against consistent Premier claims management expectations.
- Correspond and interview with medical specialists, agents, witnesses, or claimants to compile information
- Take accurate and detailed statements from all involved parties
- Calculate and approve payment of claims within a certain monetary limit
- Negotiate and settle property losses with little oversight
- Coordinate with legal counsel in handling cases correctly
- Previous experience in insurance, investigations or other related fields
- Experience in conflict resolution
- Strong negotiation skills
- Excellent written and verbal communication skills
- Deadline and detail-oriented
- Investigates significant events, claims and lawsuits presented against caregivers, physicians and facilities for liability, causation and damages. Interviews principal defendants, fact and expert witnesses completes required captioned reports. Analyzes and evaluates completed investigation and makes recommendations regarding settlement authority, trial or Alternative Dispute Resolution methods.
- Contacts non-represented claimants presenting demands for compensation beyond waiver of medical bills and analyzes liability, causation and damages to determine exposure and resolves claims by denial, settlement or alternative resolution. Establishes reserves for all litigated and non-litigated claims and lawsuits according to the claims procedure policy.
- Contacts claimant’s attorneys when notified of legal representation and exchanges discoverable information, based upon HIPPA and federal and state privacy rules to permit evaluation of claims and resolves such claims by denial or settlement with the claimant’s attorney.
- Manages litigated cases including directing defense attorneys, attending key depositions, meditations, settlement conferences and select portions of trials. Determines the utilization of adjunct claims management services such as litigation stress consultants, witness preparation consultations, focus groups, mock juries and other independent consultants as needed in each case.
- Coordinates the production of documents, interviews of witnesses and depositions with the regional risk managers. Reviews requested documents before releasing to defense counsel.
- Attends quarterly claims strategy conference calls. Participates in conference calls with excess insurance carriers as needed.
- Provides progress reports to physicians and key nursing staff as investigation develops. Informs all targeted practitioners of the impact of federal (NPDB), state (MQAC), insurance and underwriting guidelines concerning settlements, awards and verdicts.
- Compiles high-level reports from events, claims and lawsuits using sophisticated data analytic tools. Enters data into the data system for document management.
- Provides advice to practitioner and administrators.
- Performs other duties as assigned.
- Bachelor’s degree in Business Administration, Insurance, Legal or Healthcare related field and/or equivalent education/experience is required.
- Clinical background and/or Juris Doctorate strongly preferred.