5/27/2004 04143


MEDICAL MALPRACTICE CLAIMS MANAGER

DEFINITION:

This is managerial work in planning and directing the medical malpractice claims management process in a satellite or regional office of the Medical Care Availability and Reduction of Error (Mcare) Fund.

The employee in this job plans, directs, controls and evaluates the investigation, negotiation, settlement or defense of medical malpractice claims to provide fair and reasonable compensation to claimants while effectively protecting the financial viability of the Mcare Fund. Work involves settling or disposing of claims; recommending the settlement or disposition of claims valued in excess of the private carriers’ liability; and directing the development of claims defense where the Commonwealth carries total liability. Work includes developing and implementing program policies and procedures, identifying and evaluating social and economic trends affecting the medical malpractice climate to insure the proper evaluation and handling of claims, and meeting with primary insurance carriers to discuss and resolve problems concerning case handling. Supervision is exercised over a staff of subordinate supervisors and technical employees. Work is performed under the general direction of an administrative supervisor and is reviewed through conferences, reports and an evaluation of program results to determine the adherence to departmental policies and procedures.

EXAMPLES OF WORK:

Plans and directs the work of a technical and supervisory staff engaged in the evaluation, investigation, negotiation, settlement and defense of medical malpractice claims.

Manages all claims received and health care provider claims issues.

Monitors the performance of assigned defense counsel.

Directs the analysis of insurance provider claims files to ensure the adequacy of their investigation and defense strategies.

Directs the development of proof of claims and defense case development.

Represents and promotes the interests of the Office of Mcare with representatives of the medical insurance industry and health care provider community.

Performs the full range of supervisory duties.

Employees in this class may participate in the performance their subordinates’ work consistent with operational or organizational requirements.

Performs other related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES:

Knowledge of the functions of the Mcare Fund and Claims Administration

Knowledge of the methods and techniques of claims evaluation, investigation, settlement and defense.

Knowledge of insurance terminology and the regulations pertaining to contractual provisions of insurance policies and payment of claims.

Knowledge of general and medical malpractice insurance principles and practices.

Knowledge of the law of tort, judicial procedures, statutes of limitations, actions in assumption and trespass, and the basic rules of evidence.

Knowledge of medical terms, injuries and costs.

Knowledge of legal costs of malpractice suits and appropriateness of establishing annuities and trust agreements.

Knowledge of the principles and methods of program planning, organization, direction and interpretation.

Knowledge of the concepts, methods, techniques involved in modern management practices.

Knowledge of current social and economic trends affecting the medical professional liability insurance industry.

Ability to objectively analyze and evaluate information received to make sound recommendations and decisions.

Ability to effectively dispose of claims in accordance with Mcare Fund guidelines.

Ability to negotiate claims settlements at the lowest possible cost.

Ability to establish and maintain effective working relationships.

Ability to evaluate administrative methods and procedures and to recommend effective improvements.

Ability to develop policies and programs consistent with the mission of the Mcare Fund and compatible with trends in the medical professional liability insurance industry.

Ability to plan and direct the activities of a claims management and technical staff.

MINIMUM EXPERIENCE AND TRAINING:

One year as a Medical Malpractice Claims Supervisor;

or

Six years of experience as a medical malpractice claims examiner, which included one year of supervisory or managerial experience in medical malpractice and a bachelor’s degree.

or

Three years of experience as a medical malpractice claims examiner, which included one year of supervisory or managerial experience in medical malpractice, and an advanced degree in law (juris doctorate).