Claims Specialist (CAP Claims)

Job Description

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.
• 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.
• Timely review and index documents to the On Base system.
• Provide assistance to management as indicated on special project.
• Identify, investigate and follow-up on coverage issues.
• 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 and II’s.
• 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 five years of medical malpractice claims management experience and / or three years CAP claims experience.
• Certificates, Licenses, Registrations :
• Valid California driver license

Skills