Employment Type:

Full time

Shift:

Day Shift

Description:

Responsible for the personnel, operations, and oversight of a claims management Team in Regional Claims Office. Oversees the day-to-day operations for assigned team. Designs and directs the claim investigation process; evaluates claim with respect to liability, causation, and damages; develops a resolution strategy and fairly and equitably resolves claims and lawsuits.

ESSENTIAL FUNCTIONS:

General Management Responsibilities:

Knows, understands, incorporates, and demonstrates the mission, vision, and values of Trinity Health in leadership behaviors, practices, and decisions. Reports to and receives guidance from Director of Liability Claims and/or Director Claims Services.  Facilitates and ensures communication between the regional claims management team and system office IRMS group. Conducts regular meetings with regional team to promote clear communication, discuss responsibilities and tasks as needed, evaluate individual employee claim load, and provide guidance and support on questions or concerns as needed.

Team Management Responsibilities:

Monitors and provides input on staffing needs.  Conducts interviews, evaluates candidates, hires new staff, and provides employee orientation and training. Evaluates staff performance, ensures staff professional development, provides performance feedback, recommends salary actions, and, as necessary, develops performance improvement plans and recommends individual terminations of employment.   Develops and provides guidance related to individual and team goals. Conducts review of progress toward goals and conducts employee performance reviews. Responsible for staff scheduling to include work assignments, employee training, PTO, leaves of absence, trial coverage, etc.  Approves PTO, sick time, and process time off for Team in Kronos timekeeping system. Schedules and conducts regular Team meetings. Approves staff expense reports and time sheets.  Ensures compliance with required Trinity Health corporate education and compliance. Reviews claim loss reports, assesses complexity of submitted claims and assigns claims as appropriate; serves as a resource for staff to address and resolve issues, as needed. Addresses, resolves and/or escalates technical, legal and claims management issues that may arise.  Monitors work assignments and re-assigns cases/venues as needed to ensure appropriate staffing. Ensures adherence to Trinity Health IRMS policies and procedures. Identifies, recommends, and participates in the development/modification and communication of policies and procedures as appropriate. 

Claim Management Responsibilities:

Conducts review of new incidents, PCEs, lawsuits, SREs, and ADCs and analyzes whether an incident needs to be promoted to a claim, whether an Area Claims Manager (ACM) or Claims Specialist (CS) needs to be assigned, and whether any other further action needs to be taken.  Assesses coverage in coordination with assigned claim manager, and partners with Risk Finance relative to complex insurance coverage issues that may arise.  Conducts regular reviews of open files and meets with team members to ensure claims are managed in accordance with best practices.  Considers upcoming actuarial dates and encourages reserve assessment, claim opening and closure in accordance with target dates. Works with assigned team relative to management of defense counsel.  This includes:

• Selection of counsel for new matters in conjunction with the Director, Liability Claims and/or Director, Claims Services, when applicable;
• Ensuring adherence to litigation protocol and billing guidelines;
• Oversight of file work and strategy, including selection of experts;
• Identification and resolution of conflicts pertaining to representation; and
• Settling of billing disputes as needed.

Supervises the work activities of Claims professional staff in reviewing, analyzing, investigating, negotiating, and settling claims in compliance with established standards and expectations.  Conducts file audits in Clearsight to ensure compliance with IRMS Claims Department best practices.  Reviews files to include consideration for incident location, policy period, claim description, claim data accuracy, timely and accurate best practice note completion, and reserve appropriateness.  Assesses batch claim, line of coverage, and verification of insured status.  Communicates with team regarding areas for improvement, deficiencies, and significant achievements.  Monitors and evaluates reserves for claims within the team to ensure they are adequate and that reserve adjustments are made, when necessary, consistent with established time frames. In coordination with assigned Director, facilitates annual file review for all claims and bi-annual reviews for large loss claims with panel counsel.  For non-assigned matters, ensures annual review to comply with claim management procedures.  Provides authority as needed in accordance with Settlement Authority Matrix.  For claims requiring higher level of authority, works with ACM and/or CS, as needed, to prepare requests for authority, obtain consent and risk modifications if needed, and submit to senior leadership per the Settlement Authority Matrix. In accordance with the duties and functions of an Area Claims Manager, maintains an individual caseload commensurate with the amount of time necessary to perform the duties of Senior Area Claim Manager. Individually responsible for claims management of complex, technically difficult and/or high exposure matters including, but not limited to birth trauma, catastrophic damage claims, class actions, batch claims, and complex product liability/medical device matters, including personally managing all claims with indemnity reserves of $5M or greater. 

Other Responsibilities:

Participates in Regional Claims Review and ensures matters are presented consistent with the applicable procedure.  Provides feedback regarding presented claims to ensure they are appropriately reserved in light of exposure, assesses possible alternative avenues of recovery, and discuss coverage issues as needed.

Participates in Large Loss quarterly meetings and provides strategic and tactical feedback regarding matters with indemnity reserves of $1M or greater.  Works with team to identify claims to be presented at Large Loss and that claims are presented in accordance with the applicable procedure.

In coordination with the Claim Directors, monitors performance of panel counsel and suggests changes/modifications as needed. Participates in new counsel interviews and facilitates adding new counsel to panel.

Works closely with defense counsel and claim managers to confirm all appropriate defenses/arguments are asserted relative to privilege for quality/peer review matters. Works closely with Loss Control with respect to Trinity Health's PSO, to ensure process comports with legal requirements such that appropriate protections apply.

Collaborates with Directors and other Claims Area Senior Managers to regularly evaluate administrative practices within Claims Management Department. Adheres to best practices for all communications, internally and externally.  Evaluates Claims Department systems for file management.  Recommends and coordinates needed changes based on process analysis; ensures consistency with IRMS policies and procedures. Communicates with Health Ministry (HM) Risk Management/Patient Safety colleagues relative to all aspects involving claims management.  This includes:

• Communication related to new matters, and potential exposure;
• Preservation of evidence, documents, electronic data as needed;
• Unsupportive reviews, or other significant case development as needed;
• Requests for authority and risk modifications as required per procedure; and
• Adherence to protocols (venue specific) for protected documents involved in litigation.

Serves as liaison for HM senior leadership relative to pending matters and potential exposure.  This includes:

• Requests for authority per Settlement Authority Matrix;
• Provides updates as needed regarding high exposure claims;
• Advises as to high profile/media sensitive matters; and
• Provides comprehensive claims review as requested for RHM senior leadership.

Serves as contact for various vendors including court reporting services, record copy services, trial graphics.  Oversees/assists with "Request for Proposal" for new vendors and participates in interview process and selection.  Reports to Directors regarding performance of vendors and facilitate process improvements as needed. Participates in IRMS and/or Trinity Health committees as requested by the Director, Liability Claims and/or Director, Claims Services to provide subject matter expertise. Maintains awareness of existing and proposed legislation, court decisions and emerging trends in claims litigation specific to the Team’s venue.  Recommends process and/or procedure changes as appropriate.

MINIMUM QUALIFICATIONS

Bachelor’s degree or equivalent combination of education or experience.  A clinical health care degree and/or advanced degree in law or hospital administration is desirable. 

Seven (7) years’ experience as a liability claims professional adjuster, defense malpractice attorney or hospital risk manager.

Previous leadership experience in leadership and supervision is preferred.

Advanced knowledge and working relationships in risk management, quality management and improvement is preferred.

Working knowledge of medical terminology is necessary.

Strong analytical skills are necessary as well as the ability to organize and communicate information both orally and in writing with all levels of the organization.

Initiative and the ability to handle responsibility independently are necessary.

Ability to meet deadlines and respond to shifting priorities is necessary.  Must be comfortable operating in a collaborative, shared leadership environment.

A personal presence which is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health is essential.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

Must be able to travel to the various Trinity Health sites up to 50% of the time.  (Travel to meet with other related parties at various locations is expected).

Must be able to work independently at a remote location, including but not limited, at home. 

Must be able to adapt to frequently changing work priorities as well as work under pressure.

Must be able to perform moderate physical activity, lifting and bending.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.   They are not to be construed as an exhaustive list of duties so assigned.

Hourly pay range: $57.90 - $95.55

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.