CLAIMS SPECIALIST II / SR. CLAIMS SPECIALIST

Job Description

Job Description

Description:

OVERVIEW: Performs technical and administrative duties to manage assigned claim files. Participates in the continued training and supervision of Claim Specialist I’s.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

· Manage medical malpractice claims, including the assignment, direction and control of defense counsel, under supervision and in compliance with the Claims Technical Manual, the Defense Attorney Guidelines, and the MPT Agreement. Manage increasingly complex cases with larger financial exposure. Review all bills for reasonableness.

· Investigate and evaluate claim files including complying with the standards of performance, interviewing members, reviewing medical records, corresponding with plaintiff attorneys, obtaining preliminary expert evaluation/opinions, and preparing interview summaries.

· Prepare case evaluation reports for publication and presentation to the CRC and CSC.

· Prepare case evaluation reports for discretionary authority on selected cases.

· Manage and participate in all litigation activity, including discovery plan, mediation, MSC, and negotiation under supervision, as necessary.

· Monitor trials and arbitrations including daily progress reports, providing member and defense attorney with support.

· Prepare claim file resolution documentation.

· Timely update the claims database.

· Document all important case developments under the chronology tab.

· Code the claims file and update as relevant information is available.

· Time Provide assistance to management as indicated on special project.

· Identify, investigate and follow-up on coverage issues.

· Timely review and index documents to the On Base system.

· Take Hotline calls as requested and as necessary and prepare hotlines.

· Attend staff and department meetings as indicated.

· Assist management in training of Claims Specialist I

· Perform other duties as necessary

EDUCATION and/or EXPERIENCE:

Bachelor’s degree from four-year college or university;

Relevant legal and/or medical education background or the equivalent.

Minimum three years of medical malpractice claims management experience and/or one year CAP claims experience.

CERTIFICATES, LICENSES, REGISTRATIONS:

Valid California driver license

OTHER SKILLS and ABILITIES:

Excellent demonstrated verbal and written communication skills.

Effective time management skills.

Ability to manage multiple priorities/deadlines

Personal computer literate preferred.

Strong analytical skills