Claims Manager RN

Position will require travel within state.

The Claims Manager is responsible for directing the development and systematic implementation of claims oversight program and providing strategic insight into practice, policy, procedure and education designed to reduce claims while aligning with MyMichigan health's strategic initiatives and priorities.

(50%)* Management of claims including general liability, open potentials, notice of intent, and Summons and Complaints:

Reviews variance with potential for claims and initiate claims on variance with risk of medical malpractice, general liability or requests for compensation.

Conduction clinical review of patient medical records with reported serious safety event to monitor for and identify potential risk exposures and provides leadership notification when level of harm SSE1 or SSE2.

Facilitates management of serious safety event follow up by patient safety specialist to ensuring variances are transitioned to a claim in a timely manner and appropriate follow up including but not limited to department review, RCA and peer review is completed.

Oversight of financial analyst for insurance notification, claims financial transactions, authorizing payment for legal and settlement purposes and claims reporting.

Processing and approval of claim management payments up to preapproved amount. Obtain approval for payments from appropriate resources for payments exceeding preapproved amount.

Facilitates and/or provides guidance of disclosure process including review of facts, providing talking points, promoting apology and transparency, working with the healthcare providers involved and patient / family to foster open communication. Implements ongoing resolution discussion and facilitation when applicable.

Communication with patient/families when compensation is requested regarding final decision and or settlement negotiations.

Works collaboratively to retain legal counsel and manage/monitor litigation process including but not limited to notification and support of providers involved, obtaining expert reviews, coordinating defense strategies, attending provider/attorney meetings, depositions and court hearings/trials as required.

Review of claims status for drafting of credentialing statement and NPDB reporting.

(15%)* Leads monthly Professional/General Liability Claims Management Oversight Committee.

Prepares agenda and coordinates monthly system reports including types of claims, reserves, claims updates/actions and other agenda items.

Facilitates conversation and decision making on management of claims including follow up, setting expense and indemnity reserve, retention of legal counsel and settlement options.

Completes follow up actions and updates claims files to reflect decisions made.

Review and coordinate approval minutes.

(15%)* Ensures that the Patient Safety Team and Claims Manager work in collaboration to provide resources and consultation to staff, physicians, and other professional employees throughout the system in area of medical / legal and patient safety issues.

Preparing and presenting training to increase awareness of patient safety initiatives to decrease claims.

Ongoing education to leaders on how to perform reviews at a local level including variance reviews, RCA and other process improvement.

Serve as subject matter expert for practice, policies and procedures to reduce claims.

Prepare and present MyLead quality and patient safety courses.

Coordinate review of attorney meetings, subpoenas and records requests as necessary utilizing internal legal and outside counsel when necessary.

Coordinate attorney representation for state investigations related to claims.

(15%)* Analyzes and trends system claims data to identify issues and utilizes the Risk Management information system for distribution of reports and feedback emphasizing areas for risk reduction, quality improvement, and claim prevention as necessary monthly, quarterly, and yearly.

(5%)* Participate in Michigan Hospital Group yearly meetings, quarterly phone calls and other meeting as necessary.

Prepares and presents MMH specific data.

Shares MMH best practices.

Provides RCA lessons learned.

Gather and provide MHG requested data.

OTHER DUTIES AND RESPONSIBILITIES:

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

May function in role as lead or co-lead and or serve as subject matter experts for committees across the health system.

Works with leadership and staff to create policies and procedures that ensure safe care and minimize harm to the patient.

Completes special request investigations related to actual or potential claims.

Work with auditors on a yearly basis including financial & insurance reviews

Credential: RN: Registered Nurse

Equivalent Experience:

Qualification Source:

Essential: true

Credential: NIMS IS 100: NIMS IS 100 Introduction Incident Command System

Equivalent Experience: Within 6 months of hire or transfer

Qualification Source:

Essential: true

Credential: NIMS IS 700: NIMS IS 700 Introduction National Incident Mgt System

Equivalent Experience: Within 6 months of hire or transfer

Qualification Source:

Essential: true

Credential: NIMS IS 200: NIMS IS 200 Basic Incident Command System Initial Response

Equivalent Experience: Within 6 months of hire or transfer

Qualification Source:

Essential: true

Education: BACH

Equivalent Experience: Master's degree preferred. Additional Safety/Risk certifications preferred.

Education Specialization:

Essential: true

EXPERIENCE, TRAINING AND SKILLS:

Three to five (3-5) years of experience with Risk Management.

Leadership skills needed to effectively lead a team.

Ability to monitor quality, take initiative to proactively reduce risk.

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

Knowledge of current regulatory and accreditation standards in healthcare.

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.

Education: BACH

Equivalent Experience: Master's degree preferred. Additional Safety/Risk certifications preferred.

Education Specialization:

Essential: true

Credential: RN: Registered Nurse

Equivalent Experience:

Qualification Source:

Essential: true

Credential: NIMS IS 100: NIMS IS 100 Introduction Incident Command System

Equivalent Experience: Within 6 months of hire or transfer

Qualification Source:

Essential: true

Credential: NIMS IS 700: NIMS IS 700 Introduction National Incident Mgt System

Equivalent Experience: Within 6 months of hire or transfer

Qualification Source:

Essential: true

Credential: NIMS IS 200: NIMS IS 200 Basic Incident Command System Initial Response

Equivalent Experience: Within 6 months of hire or transfer

Qualification Source:

Essential: true