Claims Specialist

Summary:
Position will be hybrid, with travel to all system locations

 

The Claims Specialist supports the organization's professional liability claims management and risk reduction strategies through an integrated approach to assess, monitor and manage claims with the goal of reducing claims while aligning with MyMichigan Health's strategic framework.

Responsibilities:
(20%)*Works with variance reporting system to transition variances to claims. Completes details review of variance, including initial report, follow-up actions, final severity rating and additional quality reviews. Monitors of open potentials for additional legal action. Timely updates claims including attaching pertinent data and legal correspondences. Approves billing and processes check requisitions related to claims.

(20)%*Facilitates management of serious safety event in coordination with patient safety specialist ensuring variances are transitioned to claim in a timely manner and appropriate follow up including, but not limited to department review, RCA and peer review is completed. Participates in RCA process for all potential SSE reviews and attaches applicable policies to claim, initiates RCA action plan monitoring and for appropriate billing waivers.

(20%)*Facilitates and/or provides guidance of disclosure process including review of facts, provides talking points, promotes apology and transparency, working with healthcare providers involved and patient/family to foster open communication. Implements on going resolution discussion and facilitation when applicable. Communication with patient/families when compensation is requested regarding final decision and or settlement negotiations.

(20%)*Coordinates and participates in legal meetings with staff and retained counsel. Including scheduling room reservation and confirmation. Provides access to EMR during meetings for staff assistance in reviewing care. Reviews and provides medical records to retained attorneys.

(10%)*Rounds timely with patient safety and patient relations to assess and address real or potential legal concerns. Follows up with departmental managers and leadership regarding legal concern and recommends risk reduction strategies. Provides proactive education on risk mitigation and reduction.

(10%)*Participates in report writing and management of MyVoice variance report writing technology, Origami and Section 111. Analyzes system date to identify trends.

 

OTHER DUTIES AND RESPONSIBILITIES:

Facilitates team to address opportunities for risk reduction.

 

Provides backup for claim manager for mandatory events and time of inaccessibility.

 

Leads initiatives for high priority opportunities as identified by leadership.

 

Serves as a liaison for claims and legal counsel that may require case review and file development.

 

 

Certifications and Licensures:
BLS: Basic Life Support Within 1 month of hire or transfer.

 

Required Education:
Bachelor degree is required

Bachelor's degree in business or healthcare related field. Additional Quality/Patient Safety certifications preferred.

 

Other Information:
EXPERIENCE, TRAINING AND SKILLS:

Three to five (3-5) years of clinical experience. Three to five (3-5) year's experience in patient safety or quality role with claims exposure.

 

Ability to monitor claims and participate in the medical malpractice process.

 

Experience in root cause analysis, timeline, policy research, and action plan development and monitoring.

 

Knowledge of software utilized for variance and claims reporting at a safety specialist, supervisor or manager level.

 

Problem-solving techniques/expertise, interpersonal and customer service skills, oral and written communication skills and the ability to speak in a public forum.

 

Interpersonal skills needed to communicate successfully with individuals and groups and interact with people at all levels to communicate ideas and concepts in a clear and understandable manner.

 

MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.

 

PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:

Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.

 

Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.

 

Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.

 

Overall vision and hearing is necessary with or without assisted device(s).

 

Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.

 

Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.

 

Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.

 

Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.

 

Physical Demand Level:Light. Must be able to occasionally (0-33% of the workday) lift or carry 11-20 lbs., frequently (34-66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.

 

 

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