Claims Investigator

Job Details : Job Summary :

Job Summary :

The Claims Investigator is responsible for the management and investigation of medical malpractice, general liability and lost / stolen or damaged property claims.

This individual will conduct investigations of complex, claims and lawsuits filed against the hospital in preparation for, or in the context of legal action.

This position works with considerable independence with a wide scope of knowledge in order to exercise independent judgment within established policies and procedures.

This position will also be responsible for related work as required or directed by Risk Management Leadership Team.

Responsibilities :

• Reviews and analyzes medical records and hospital policies and procedures to identify key issues and assess the hospital’s exposure in preparation for legal action related to a sentinel event or incident that is the subject of a Notice of Claim or Summons;
• Investigates confidential and complex circumstances that may result in a liability claim;
• Identifies and interviews named defendants insured through the hospital’s professional liability insurance program and other employed or insured personnel involved in the case;
• Identifies theories of liability and exposure and involvement of potential co-defendants;
• Prepares comprehensive and informative investigative reports containing findings, conclusion and recommendations for use by defense counsel;
• Acts as liaison with defense counsel, assisting with preparation of interrogatories, settlement discussions and preparations of cases for trial;
• Manages and coordinates the investigation and discovery of claims;
• Discusses cases with physicians, administrators, attorneys and claimants in a professional and confidential manner;
• Coordinates in-house medical reviews;
• Participates in the development and implementation of policies, practices and procedures designed to meet risk management program goals and objectives for efficient and effective claims management to ensure compliance with regulations and codes;
• Makes recommendations on issues, practices and procedures aimed at limiting long term liability exposure;
• Develops and conducts programs designed to educate staff;
• Monitors indemnity / expense ratio;
• Monitors reserves with written evaluation of high exposure claims in compliance with reporting requirements;

Qualifications / Requirements /

Experience :

• Thorough knowledge of claims management functions related to a hospital or health care delivery setting; thorough knowledge of the principles, practices, procedures and techniques utilized in planning and conducting confidential investigations;
• thorough knowledge of medical malpractice and general liability claims management; good knowledge of the principles and practices of hospital organization as related to the functions of its various divisions, regulatory agencies and accrediting organizations;
• ability to establish and maintain effective working relationships with a wide range of medical, professional, administrative and clerical personnel;
• ability to communicate effectively, both orally and in writing; ability to prepare accurate and informative reports; ability to perform work independently and exercise sound judgement within established policies;
• ability to effectively use computer applications such as spreadsheets, word processing, calendar, email and database software in performing work assignments;
• ability to read, write, speak, understand and communicate in English sufficiently to perform the essential duties of the position;

thoroughness; integrity; tact; initiative; resourcefulness; physical condition commensurate with the demands of the position.

Ability to demonstrate flexibility in work assignments and re-prioritize activities to meet department’s needs and expectations.

Strong organizational and time management skills are essential to complete time sensitive investigations and reports.

Education :

Bachelor’s degree in Nursing or related field plus three years experience where the primary function of the position was the investigation and / or analysis of health care related liability claims

Licenses / Certifications :

New York State Education Department Registered Professional Nurse or Allied Healthcare Professional Clinical Background preferred

Other :

Computer skills literacy and familiarity with navigation of electronic medical record systems