to: Chief Risk Officer
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.
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.
with people by calling them their proper name, or the name they prefer (Mr.,
yourself and your role.
what you are going to do, how long it will take, and how it will impact the
permission before entering a room, examining a patient, or undertaking an
to patient’s questions or requests promptly; anticipate patient needs.
courteously with an explanation of what will come next.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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.
Responsible for compliance activities with California
Medical Board, National Practitioner’s Database, and Medicare.
Provides external consulting services to third party
clients in line with area of expertise and job function.
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.
Doctor (JD) degree from an accredited school of law.
for admission to the California Bar.
(7) years of progressively responsible and directly related work experience
Knowledge, Skills and Abilities
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.
to travel (both domestically and internationally) and work remotely as part of
normal job duties
to develop long-range business plans and strategy
to evaluate claims and determing reserve requirements
to foster effective working relationships and build consensus
to mediate and resolve complex problems and issues
to negotiate with insurance brokers
to provide leadership and influence others
of claims handling management
of commercial brokerage firms and operations
of insurance policy structure and modification of terms and conditions
of local, state and federal regulatory requirement related to the functional
of medical and legal terminology
of principles and practices of organization, administration, fiscal and
of reinsurance principals and coverage structure
PHYSICAL REQUIREMENTS/WORK ENVIRONMENT
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