DIRECTOR-CLAIMS AND LITIGATION STRATEGY

General Search & Recruitement Published: November 8, 2018
Location
San Francisco, CA
Category
Job ID
Job-1144

Description

DIRECTOR-CLAIMS AND
LITIGATION STRATEGY

 

 

Job
Attributes

 

  • Job
    Code:  101526

  • Job
    Family:  Finance

  • Bargaining
    Unit:  



    Non-Union

  • FLSA
    Status:  



    Exempt

  • Reports
    to:  Chief Risk Officer

  • Created/Revised:
     3/24/2017

 

Job Summary

 

Reporting to the EVP
Claims and Risk Management, Larry Gray, this position is responsible for the
day to day administration and general operations of the claims program,
including oversight of internal and external claims personnel, maintenance of
claims data system and interaction with insurance brokers as needed. This
position is responsible for establishing, developing, and utilizing claims
policies and guidelines, reviewing insurance coverage, evaluating claims for
liability and compensability, setting case reserves through the DARTS
(Decision Analysis Reserve Targeting Strategy) process, securing necessary
information for claims and litigation, and the negotiation and settlement of
claims. Coordinates with the Office of General Counsel, and the Chief Risk
Officer on the strategic and long-term evaluation and resolution of all
claims. Provides risk management advice related to patient care issues.

 

Essential Functions

 

The essential
functions listed are typical examples of work performed by positions in this
job classification, and are not designed to contain or be interpreted as a
comprehensive inventory of all duties, tasks, and responsibilities.  
Specific
duties and responsibilities may vary depending on department or program needs
without changing the general nature and scope of the job or level of
responsibility.  Employees may also
perform other duties as assigned.

  • Employees must abide by all Joint Commission
    requirements including, but not limited to, sensitivity to cultural diversity,
    patient care, patients’ rights and ethical treatment, safety and security of
    physical environments, emergency management, teamwork, respect for others,
    participation in ongoing education and training, communication and adherence to
    safety and quality programs, sustaining compliance with National Patient Safety
    Goals, and licensure and health screenings.

  • Employees must perform all duties and
    responsibilities in accordance with the C-I-CARE Standards of the Hospital.
    C-I-CARE is the foundation of Stanford’s patient-experience and represents a
    framework for patient-centered interactions.

     

C

CONNECT
with people by calling them their proper name, or the name they prefer (Mr.,
Mrs., Dr.)

I

INTRODUCE
yourself and your role.

C

COMMUNICATE
what you are going to do, how long it will take, and how it will impact the
patient.

A

ASK
permission before entering a room, examining a patient, or undertaking an
activity.

R

RESPOND
to patient’s questions or requests promptly; anticipate patient needs.

E

EXIT
courteously with an explanation of what will come next.

 

1)     
Acts as an education resource and provides consultation to
medical, administrative, and other staff members as requested. Provides risk
management advice related to patient care issues.

2)     
Analyzes claims activities and prepares reports for
management. Informs management of any significant claim developments.
Maintains the data and quality control of the claims system. Handles all
reported matters from initial report to resolution in an efficient and cost
effective manner, as well as external reporting to NPDB (National
Practitioners Database), California Medical Board, and Medicare.

3)     
Assists in preparation of insured’s defense as appropriate
and needed. Conducts thorough evaluation of claims to include decision tree
analysis, settlement and verdict value, and jury research when needed.

4)     
Attends mediations, settlement conferences and trials as
needed. Audits accounts, conducts file reviews, and meets with defense
counsel. Informs Chief Risk Officer (CRO) and Office of General Counsel of
significant claim developments.

5)     
Grants settlement authority after coordination with the
Chief Risk Officer, on each claim within designated authority. Assures the
accuracy and timeliness of new claim setups. Maintains existing and develops
new claims policies and procedures to improve the overall operating efficiency
and expense controls of the department.

6)     
Maintains existing and develops new claims policies and
procedures to improve the overall function of the department. Responsible for
establishing, developing, and utilizing claims policies and guidelines and implementation
of the claims procedures.

7)     
Manages assigned staff to include performance evaluations,
recognition and disciplinary issues. Assists CRO in adding new services
without increasing labor costs. Management of staff shall include the periodic
evaluations, performance reviews, and employee motivation and disciplinary
actions as needed.

8)     
Monitors ALAE (Allocated Loss Adjustment Expenses) and
continually identify ways to decrease expenses. Provides guidance and
assistance, as well as management and oversight of the day to day operations
of other claims staff and functional areas. Keeps current on state/territory
regulations and issues as well as industry activity and trends.

9)     
Oversees and manages the DARTS process (Decision Analysis
Reserve Targeting Strategy) to create an early and robust understanding of the
exposure in claims, both to establish appropriate loss reserves and to guide
case management. Establishes appropriate reserves in coordination with claims
team, including the Director, Claims and Litigation Operations, and updates
reserves when necessary.

10)   
Oversees and manages the PEARL (Process for Early
Assessment, Resolution and Learning) communications resolutions program on
behalf of Chief Risk Officer. Ensures optimal execution of program in
alignment with defined process

11)   
Administers claims program in compliance with ISO 9000
quality standard. Maintains the program’s ISO certification by overseeing
periodic internal and external audits as well as the Quality Management System

12)   
Prepares and presents reports to the Office of General
Counsel (OGC) related to all medical malpractice cases. Conducts legal issues
research on medical practice to ensure adequate reserve setting.

13)   
Responsible for compliance activities with California
Medical Board, National Practitioner’s Database, and Medicare.

14)   
Provides external consulting services to third party
clients in line with area of expertise and job function.

 

Minimum Qualifications

 

Any combination of
education and experience that would likely provide the required knowledge,
skills and abilities as well as possession of any required licenses or
certifications is qualifying.

 

Education

·       
Juris
Doctor (JD) degree from an accredited school of law.

·       
Eligible
for admission to the California Bar.

 

Experience

·       
Seven
(7) years of progressively responsible and directly related work experience

 

License/Certifications

·       
None
required

 

Knowledge, Skills and Abilities

 

These
are the observable and measurable attributes and skills required to perform
successfully the essential functions of the job and are generally demonstrated
through qualifying experience, education, or licensure/certification.

 

·       
Ability
to travel (both domestically and internationally) and work remotely as part of
normal job duties

·       
Ability
to develop long-range business plans and strategy

·       
Ability
to evaluate claims and determing reserve requirements

·       
Ability
to foster effective working relationships and build consensus

·       
Ability
to mediate and resolve complex problems and issues

·       
Ability
to negotiate with insurance brokers

·       
Ability
to provide leadership and influence others

·       
Knowledge
of claims handling management

·       
Knowledge
of commercial brokerage firms and operations

·       
Knowledge
of insurance policy structure and modification of terms and conditions

·       
Knowledge
of local, state and federal regulatory requirement related to the functional
area

·       
Knowledge
of medical and legal terminology

·       
Knowledge
of principles and practices of organization, administration, fiscal and
personnel management

·       
Knowledge
of reinsurance principals and coverage structure



 

 

Physical Requirements/Working
Conditions

 

PHYSICAL REQUIREMENTS/WORK ENVIRONMENT

·       
The
Physical Requirements and Working Conditions in which the job is typically
performed are available from the Occupational Health Department. Reasonable
accommodations will be made to enable individuals with disabilities to perform
the essential functions of the job

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