4/26/2005 04300

MEDICAL MALPRACTICE CLAIMS EXAMINER 1

DEFINITION:

This is technical work in determining the liability of the Commonwealth and negotiating settlements of medical malpractice claims against health care providers.

An employee in this job evaluates and negotiates the settlement of medical malpractice claims exceeding the maximum privately insured value of health care providers legally operating within the Commonwealth to effectively protect the financial liability of the Office of Medical Care Availability and Reduction of Error Fund (Mcare). Work involves assessing the liability of individual health care providers and the total liability of claims involving multiple health care providers; reviewing the progress of investigations to assure the effective development of defense against claims exceeding their maximum liability limits; and developing claims defense where the Commonwealth carries total liability. Work also involves negotiating pre-arbitration and pre-civil litigation settlements of claims; estimating preliminary and final claim value; estimating insurance companies’ share of liability in cases involving multiple defendants; and preparing claims summaries, defense tactics, and recommended maximum settlement offers. Work is performed independently within prescribed dollar limits and is reviewed by a technical supervisor for thoroughness od claims valuation, effectiveness of defense development strategies, and the execution and skill in negotiating settlements.

EXAMPLES OF WORK:

Investigates and analyzes the progression of medical malpractice lawsuits and claims toward a case disposition.

Evaluates claims files to determine dollar limits of claims settlement offers involving lump sum settlements, annuities, and/or trust agreements.

Analyzes claim files of insurance providers to assess adequacy of investigation and defense strategies,

Assesses percentage of liability of individual health care providers in conjunction with the analysis of total liability in claims involving multiple health care provider defendants.

Oversees the development of legal documents setting forth the obligations of various parties to the settlement of claim disputes.

Develops strategies for and directs the development of defense of claims and maximum dollar settlements.

Negotiate medical malpractice claims settlements within maximum limits authorized by claims management.

Participates in conferences and attends trials to assess strategic position in order to limit the total financial outcome to the Mcare Fund.

Prepares reports and correspondence for use in the development of defense of claims or appropriate claim disposition.

Negotiates catastrophic injury monetary settlements with plaintiff attorneys, judges and health care provider representatives.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES:

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

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

Knowledge of insurance principles and practices.

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

Knowledge of medical terms, injuries, and costs.

Knowledge of the records and documents normally maintained by health care providers and insurance companies.

Ability to interpret and apply Pennsylvania medical malpractice litigation law.

Ability to interpret medical records to determine standard of care and causation of an injury sustained.

Ability to gather information through correspondence, personal contact, and review of records, documents, and files.

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

Ability to effectively negotiate claims settlements at the lowest possible cost.

Ability to maintain effective working relationships with claimants; counsel, insurance industry representatives, defense attorneys, defendants, and co-workers.

MINIMUM EXPERIENCE AND TRAINING:

Three years of experience in examining or negotiating settlement of medical malpractice claims and a bachelor’s degree;

or

An advanced degree in law (jurist doctorate).