4/26/2005 04310

MEDICAL MALPRACTICE CLAIMS EXAMINER 2

DEFINITION:

This is advanced 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 complex medical malpractice claims involving first dollar, multiple limits of exposure or major injury severity as defined by the National Association of Insurance Commissioners (NAIC) 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 in claims involving multiple health care providers; reviewing the progress of private medical malpractice investigations to assure the development of defense against claims exceeding their maximum liability limits; and independently developing claims defense where the Commonwealth carries total liability. Work includes negotiating injury settlements with legal representatives of injured parties; negotiating pre-arbitration and pre-civil litigation settlements of claims; estimating preliminary and final claim value; and preparing claims summaries, defense tactics, and recommended maximum settlement offers. Work also involves the analysis of medical and legal circumstances to dispose of high financial exposure claims at a reasonable financial cost. Work at this level is distinguished from the next lower job by the responsibility for determining first dollar exposure and handling claims having multiple limits of exposure, complex coverage issues or an injury severity code of level 8 as defined by the NAIC. Work is performed independently and is reviewed by a Medical Malpractice Claims Manager through conferences, reports and meetings to evaluate effectiveness of results for adherence to departmental policies and procedures.

EXAMPLES OF WORK:

Determines first dollar exposure and investigates claims having multiple limits of exposure, complex coverage issues or an injury severity code of 8 as defined by the NAIC.

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

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

Analyzes the review of insurance providers’ claims files 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 one or multiple health care provider defendants.

Develops legal documents that outline 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.

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

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

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

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

Performs 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, negotiation, settlement and defense of medical malpractice claims

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, statures 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 records and documents normally maintained by health care providers and insurance companies.

Ability to interpret and apply knowledge of Pennsylvania medical malpractice litigation law, and state and federal case law.

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

Ability to apply the methods and techniques of claims evaluation, investigation, settlement, and defense of medical malpractice claims.

Ability to gather, interpret and apply 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:

One year as a Medical Malpractice Claims Examiner 1;

or

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

or


One year of experience in examining or negotiating the settlement of medical malpractice claims and an advanced degree in law (juris doctorate).