POSITION SUMMARY
This position is a high impact role responsible for cost effective and successful management of complex, potentially high exposure claims while providing legal counsel on risk management, claims and litigation matters across Banner Health (BH). The role combines advanced litigation and claims management expertise with legal acumen to manage complex and potentially high exposure professional liability claims, multi-party litigation, and other areas of liability exposure to the organization. The position designs and directs the claims investigation process; evaluates each claim with respect to liability (standard of care -SOC), causation and damages; manages and directs outside counsel; employs cutting edge litigation management strategies to optimize outcomes; and develops equitable resolution strategies for claims and lawsuits.
The primary focus of the position is Hospital and Physician Professional Liability (HPL) claims. The position may also manage or co-manage other claims and litigation across the Banner Health (BH) system, including General Liability (GL), Employment Practices (EPL) and Management Liability claims, or others as assigned.
CORE FUNCTIONS
1. Knows, understands, incorporates and demonstrates the mission, vision, values, brand, strategic initiatives, core measures and core behaviors into leadership behaviors, practices and decisions. Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of BH with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
2. Implements best-in-class claims and litigation management strategies. Responsible for the investigation, evaluation and management (or co-management) of complex, potentially high exposure claims through resolution. Evaluates and analyzes insurance coverage, notices claims appropriately to carriers, and communicates and collaborates with insurers and reinsurers. Negotiates directly with claimants and attorneys on serious liability exposures. Requires extensive interaction with all levels of senior management, physicians, CEO’s, internal management, other BH personnel, attorneys, mediators, insurance companies, business personnel, and government agencies. Directs attorney-client privileged investigations. Has independent authority to resolve claims on behalf of the organization within established authority levels. Uses specialized knowledge and independent judgment to make operational, financial, and strategic decisions affecting outcomes throughout the company.
3. Either directly on assigned cases, or as an expert consultant to other Claims team members, drives resolution of claims by formulating and implementing a thorough investigation plan and defense strategy for each claim. Evaluates each claim with respect to standard of care, liability, causation, and damages. Determines whether a preservation hold has been or needs to be issued. Considers witness credibility and consultants/expert opinions and determines the value of the claim. Determines and sets appropriate indemnity and expense reserves in a timely manner and periodically re-evaluates such reserves. Maintains a diary system to monitor all open claims. Updates claim files per documentation guidelines. Apprises Sr. Director, Claims & Litigation Counsel of case developments as appropriate. Obtains settlement authority as established by policy. Within delegated authority limits, independently negotiates or directs the negotiation of the claims/lawsuits to resolution. Represents facility, physician, and or BH at case evaluations, pre-mediation meetings with families and mediators, mediations and trial. Notifies reinsurer of selected claims according to established criteria and provides file updates pursuant to reporting guidelines.
4. Responsible for obtaining, entering data into claim file and monitoring such data in order to comply with deadlines for meeting Medicare, Medicaid, Ship Extension Act (MMSEA) reporting requirements in relation to claimants and others releasing medical expense claims. Responsible for determining amounts of liens, rights of recovery and rights of reimbursement with regard to Medicare Secondary Payer Act, other state, federal, and private third-party payers and adheres to all state and federal laws, rules and regulations.
5. Serves as a trusted advisor to internal clients, building strong, collaborative relationships. Provides legal advice and counsel to employees and leadership relating to risk management issues, risk mitigation issues, and settlement and litigation strategies. Provides legal advice and direction to the organization with respect to incidents, potentially compensable events, claims, or suits and insurance coverage issues. Directs privileged investigations. Provides timely, clear and professional communications including written reports, presentations and claim evaluations.
6. Participates in the attorney selection and re-evaluation process with the Sr. Director, Claims and Litigation Counsel. Retains approved defense counsel on a per claim basis after checking conflicts. Directs and supervises the work of outside defense counsel pursuant to litigation protocol. Reviews and responds to attorney inquiries, reports and recommendations as appropriate. Reviews and approves the defense counsel fees and litigation expenses. In conjunction with defense counsel establishes a claim resolution strategy, facilitates and communicates same. Provides guidance and clarity to other team members relating to litigated matters.
7. Presents comprehensive information at internal claim reviews and prepares case review material. Provides status reports for both open and closed claims as requested. Responsible for creating, monitoring and updating policies and procedures for the Sr. Director, Claims and Litigation Counsel, and VP, Chief Risk Officer & Counsel.
8. Identifies risk management issues and makes recommendations as appropriate. Documents risk modification and risk reduction strategies in claims file and in database. Works collaboratively with the risk managers to identify risk management trends, issues and opportunities and brings those learnings back to the broader organization. Provides education and training throughout the system on risk and litigation mitigation strategies.
9. Directs and supervises Litigation Management Specialists/Paralegals and Information Analyst/s in handling claim files, creating reports, database entries and other claim management responsibilities. Provides periodic feedback to staff regarding expectations and performance and completes the performance evaluation process for assigned staff. Directs interviews and hiring process, creates and implements orientation plan, provides guidance to new associates and evaluates progress to plan.
MINIMUM QUALIFICATIONS
This position requires completion of a Juris Doctorate (J.D.) and admission to at least one state bar, and a minimum of eight to ten years medical professional liability management experience, either as an in-house claims professional or outside counsel.
Must gain admission to AZ bar through reciprocity or in-house counsel provision within one year of hire date.
Strong negotiating skills and a working knowledge of medical terminology are required. Strong analytical skills are necessary as well as the ability to organize and communicate information both orally and in writing with all levels of the organization. Initiative and the ability to handle responsibility independently are necessary; must have the ability to deal with conflict in a non-confrontational manner and possess the ability to handle sensitive situations and information in a calm mature manner. Ability to meet deadlines and to respond to shifting priorities is necessary. Must be comfortable operating in a collaborative, shared leadership environment. Must be able to adapt to frequently changing work priorities, as well as to work under pressure.
Must be able to travel to various BH sites or other locations for litigation management purposes up to 50% of the time. Must be able to travel to meet with other related parties at various locations is expected.
PREFERRED QUALIFICATIONS
Nursing degree or other clinical background. Advanced knowledge of healthcare claims, risk management, insurance, quality management and performance improvement.
Knowledge of in-house liability claims management processes and procedures and other related healthcare regulatory and/or litigation experience. Prior managerial experience within a healthcare system setting or other large multi-operational, complex corporate environment.
Additional related education and/or experience preferred.
