DESCRIPTION

ReqID: 380801
Job Category: Clinical Quality
Shift: Day
Schedule: Full time
Work Location: Providence Valley Office Park-Renton

KNOWLEDGE REQUIRED FOR THIS POSITION INCLUDE:

• Healthcare professional liability and/or other civil tort claims handling practices
• Medicare Secondary Payer reporting requirements for third party liability claims
• Reporting to regulatory agencies and state licensing boards
• Insurance Commission requirements within Providence’s footprint
• Insurance terminology
• Legal concepts
• Liens
• Electronic claims databases
• Medical terminology

SKILLS REQUIRED FOR THIS POSITION INCLUDE:

• Third-party liability claims management skills, including healthcare professional liability and/or other types of civil tort claims
• Exceptional analytical skills
• Communicates respectfully, professionally, concisely, and diplomatically
• Interpersonal skills, including active listening
• Performs challenging tasks with efficacy
• Outstanding organizational skills, including time management, prioritization, and collaboration
• Initiative-taking
• Adaptability
• Self-management skills
• Digital literacy, including navigating within an electronic claims environment

ABILITIES REQUIRED FOR THIS POSITION INCLUDE:

• Exercises critical thinking and creative problem-solving when performing job duties
• Act as a resource to fellow caregivers for MSP, regulatory, and state licensing reporting
• Ability to train fellow caregivers
• Effectively articulate ideas and information
• Open to constructive feedback
• Collaborate with others
• Demonstrate teamwork
• Ability to work autonomously in fast-paced work environment
• Demonstrate positivity in response to change

REQUIRED QUALIFICATIONS:

• Bachelor’s Degree in Business Administration, Public Health Administration, Organizational Leadership, Finance, or a related discipline -OR- a combination of equivalent education and work experience

PREFERRED QUALIFICATIONS:

• Coursework/Training: Liability claims training within the insurance industry
• 5 or more years of experience handling healthcare professional liability and/or other types of civil tort claims within the insurance industry or similarly structured self-insured organization
• 5 or more years of experience reporting third party liability settlements to Centers for Medicare and Medicaid Services (CMS), and federal and state licensing and/or regulatory agencies, including the National Practitioner’s Database (NPDB)
• Experience reviewing claims files for quality assurance purposes
• Experience working with claims data analytics
• Experience in project management
• Experience creating and facilitating claims management training
• Experience developing policies and procedures

ESSENTIAL FUNCTIONS:

• Ensure compliance with applicable laws, insurance regulations, settlement reporting, and other regulatory reporting requirements governing liability claims handling
• Develop and provide training, job aides and technical support for caregivers regarding Centers for Medicare and Medicaid Services (CMS) Medicare Secondary Payer reporting, applicable laws, insurance regulations, and other regulations relating to investigating, evaluating, and resolving liability claims. Provide empirically-based input as to training topics
• Act as a resource to fellow caregivers for Medicare Secondary Payer reporting of third-party claim payments and write-offs and serve as our mandatory reporting authorized representative
• Facilitate monthly claims files internal audits including monthly trending analysis reporting from platform analytics, compare as to organizational metrics, and propose opportunity solutions and success replication. Propose monthly audit focus topics to claims leaders based on trending analysis. Review claim files from a quality assurance perspective to ensure compliance with applicable laws, insurance codes, regulations, and our department’s policies and procedures
• Secure monthly claims data reports and provide quality assurance recommendations to claims leaders for both indicated opportunity areas relative to organizational metrics and KPIs, compliance, best practices as well as broader application potential of high-performance indicators
• Identify and provide feedback to department leaders for claims management improvement opportunities and claims-related trends through audit, data analytics, and training observations
• Recommend improvement opportunities relating to workflow efficiencies and operationalization to department leaders
• Act as a resource and to fellow caregivers regarding applicable federal, state, and local laws, insurance codes, and regulations relating to liability claims handling, including healthcare professional and general liability matters
• Assist department leaders in developing policies and procedures, as requested
• Manage payor contracting requests for claims histories
• Perform claims-related research
• Ensure appropriate reporting of claims to excess liability insurers