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Director of Claims & Senior Counsel

Job ID: R-27265 Job Type: Full time Location: Kansas City, Kansas
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Position Summary / Career Interest:

The Director of Claims & Senior Counsel for The University of Kansas Health System (TUKHS) has broad responsibility for identification, prevention, and mitigation of actual and potential risk to TUKHS, including The University of Kansas Hospital Authority (UKHA) facilities and providers across all campuses and locations, managing professional and general liability claims for the Kansas City and Southwest Kansas City markets. Priority claims responsibility will be provided for the Southwest Kansas City market. Primary responsibilities also include supporting legal department functions with TUKHS’s Office of the General Counsel, including legal advice on HIPAA-related matters, assisting with development/coordination of clinical risk management programs; providing guidance on potential sources of loss/risk and mitigation strategies; counseling and advising on potential liability and regulatory exposures; and collaborating with TUKHS, The University of Kansas Physicians (UKP) and Kansas University Medical Center (KUMC) compliance, risk, and regulatory departments, as well as governmental and regulatory agencies. The Director of Claims & Senior Counsel partners with TUKHS Clinical Risk Management in monitoring and analyzing patient safety events and providing education to practitioners on claims and risk mitigation strategies, acting as a consultant to leadership on promoting a culture of safety. Duties include maintaining responsibility for protection of the health system, its employed practitioners, and affiliates in management of insurance claims, including investigation, recommendations for action/remedy. This position collaborates closely with Directors of Insurance, Claims, Clinical Risk Management, Patient Safety/Quality, Compliance, and Patient Relations.

Responsibilities:

  • Report, respond to, review, and resolve claims, in accordance with TUKHS’s Communication and Resolution Program.
  • Participate as member of facility or enterprise crisis management teams pursuant to applicable policies.
  • Collaborate as requested with TUKHS hospital medical staff offices and medical staff leadership to facilitate investigations, assuring all relevant privileges and protections are triggered/preserved.
  • Present claims to Claims Committees for TUKHS’s Risk Retention Group and Captive.
  • Participate with Senior Leadership and legal counsel in formulating defense strategies.
  • Maintain strong relationships with various stakeholders, including, but not limited to, incumbent broker(s), captive manager, third party claim administrators, the Health Care Stabilization Fund (HCSF), excess carriers and reinsurers, and defense law firms.
  • Counsel practitioners on process and procedures involved with root cause analysis meetings and investigations, providing support as needed.
  • Assist practitioners with answering questions on licensure and credentialing applications which includes obtaining necessary documents to accompany the application.
  • Assist with reviewing patient warning letters, discharge outpatient care, and termination letters.
  • Collaborate with Human Resources, when needed, to ensure that HR-related issues and findings are effectively documented, and necessary corrective actions are taken.
  • Notify the HCSF of potentially compensable events, claims, or lawsuits.
  • As requested by the HCSF, assist with preparation for trial, including sending litigation holds, and assisting with discovery.
  • Request medical records and copies of bills for patient complaints, demands, and claims.
  • Provide independent, unbiased, and discrete assistance to TUKHS practitioners regarding potential claims at the pre-claim stage; and investigate cases identified as potential risk issues, with a goal of mitigating professional liability exposure and harm to professional reputation.
  • Attend mediations and trials on behalf of TUKHS providers
  • Review and track claims identifying potential risk issues.
  • Review and investigate patient/family complaints, patient demand letters, and incident reports; make recommendations to HCSF if requested regarding disposition of complaints and demands.
  • Assist providers with response to patient complaints in coordination with the Clinical Risk Management and Patient Relations departments.
  • Work directly with the HIPAA regulatory team to support compliance activities.
  • Maintain current awareness of federal and state HIPAA privacy and security requirements.
  • Assist, when called upon, to assure compliance with various codes, laws, rules, and regulations concerning patient care (including those mandated by state and federal agencies), incident reporting and investigation activities in support of Legal, Compliance, and Clinical Risk and Regulatory departments. Request bill holds, make recommendations for waiver of bills, and attend bill-hold meetings.
  • When necessary or prudent, request counsel for practitioners and, as requested by the HCSF, serve as the liaison to attorneys for requests to interview practitioners, obtain depositions for subsequent treating practitioners, and identify and prepare witnesses.
  •  Collaborate with Legal, Compliance, Clinical Risk and Regulatory leadership, as needed, to facilitate responses, including corrective actions to any Statement of Deficiency involving the OIG, OCR, KDHE, FDA, FBI, CMS and other regulatory and/or enforcement agencies Assist practitioners with responses to licensure board complaints; insurance grievances; and insurance peer review issues. Respond to requests for information and subpoenas from various agencies.
  • Review proposed TUKHS policies, programs, agreements, and relationships from a risk perspective, to identify and minimize risk where appropriate.
  • Review collected data to identify trends regarding accidents, incidents, claims and/or occurrences, preparing analysis and reports, and recommending corrective action to TUKHS leadership and Board of Directors.
  • Assist with oversight for maintenance of practitioner certificates of coverage and verification of insurance and claims history.
  • Assist with obtaining part-time affidavits for full-time faculty and HCSF coverage.


JOB REQUIREMENTS

Required:

  • Bachelor’s degree in Health Care, Business, or Finance
  • Five to Seven years of experience as a claims manager in a health care environment
  • Ability to manage and direct claims from start to finish (potentially compensable events, claims, suits), confirming coverage, timely reporting, assessing liability, negotiating settlements, attending mediations, and working towards informed, prompt, and fair resolution in line with TUKHS’s Communication and Resolution Program (CRP), with best reserve setting practices and respectful people-centered communication with patients, patient representatives, and visitors in accordance with claims and litigation management guidelines
  • HIPAA in-depth knowledge and expertise
  • Read, write, and speak English
  • Knowledge of regulatory codes, legal requirements and health care law issues impacting enterprise and practitioner risk.
  • Effective presentation skills; articulate, persuasive communicator
  • Self-motivated with the ability to work independently; requires little supervision
  • Ability to manage/handle stress while under pressure from many involved parties
  • Ability to interface with a variety of professionals, including Board members, medical staff and senior leadership, attorneys, accountants, actuaries, brokers, underwriters, etc.
  • Demonstrated skills in strategic planning, implementing, and evaluating programs
  • Knowledge of clinical and non-clinical loss control and claims administration
  • Ability to prioritize tasks and see the big picture
  • Ability to delegate and know when to ask for assistance
  • Demonstrated ability to offer creative, innovative solutions to prevent or reduce risk

Preferred:

  • JD (active bar membership in KS and/or MO a plus)
  • CPCU, RPLU, ARM, and/or AIC
  • CPHRM
  • MHA or MPH
  • Litigation experience
  • Ten years of experience in claims management for integrated health system(s)

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.

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