Duke University Health System (DUHS) Job Descriptions
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CLAIMS SPECIALIST
Job Title: CLAIMS SPECIALIST
Job Code: 5019
FLSA: E
Job Level: E2
Revised Date: 10/01/2018
Supervisory Responsibility: No
General Description of the Job Class
The claims specialist position provides comprehensive support for Duke University Health System's professional liability insurance operations.
Duties and Responsibilities of this Level
Professional Liability Insurance Inquiries: The Claims Specialist investigates, resolves and responds to a multitude of professional liability insurance inquires involving coverage determinations, requests for Confirmation of Coverage Letters and written Claims Histories. Requests come from a various internal sources in all practice areas across the entire DUHS spectrum including past and present DUHS staff and faculty, GME, nursing, physician assistants, CRNA, students from the School of Nursing or School of Medicine and others. External requests come from credentialing offices, insurance companies, and providers including former faculty, resident physicians, nurses, physician assistants, CRNAs, and others.
Coverage Determinations: The Claims Specialist evaluates and determines applicable insurance coverage. Durham Casualty Company, Ltd. (DCC), a captive insurance company, provides Professional Liability insurance coverage for Duke University Health System, Inc. (DUHS) and the Private Diagnostic Clinic, PLLC. In addition, PDC and various DUHS components may provide Professional Liability coverage for select programs through other carriers such as CNA, or MAG Mutual. The Claims Specialist must evaluate the facts and determine the correct applicable coverage and the correct coverage dates. The Claims Specialist interfaces with the Duke CVO, Duke GME Office, Duke Human Resources or appropriate Registrar???s Office to obtain dates of service for students or providers. The Claims Specialist prepares and submits accurate Confirmation of Coverage document to internal and external customers.
General Liability Claims: The Claims Specialist must investigate and resolve all claims made under the DCC general liability coverage. This includes investigating and assessing general liability occurrences and claims involving patient property loss and/or damage. This requires the ability to review electronic medical records, assess and determine liability, interview providers, interview patients, request indemnity reserves and negotiate monetary settlement where appropriate. The Claims Specialist has the discretion and authority to determine the settlement amount and is expected to formulate that conclusion independently through their investigation. The Claims Specialist retains responsibility for settlement negotiation, setting indemnity reserves, processing settlement payment requests and executing necessary settlement and release documents as required by Durham Casualty and Office of Counsel.
Claims Histories: A Claims History includes information of any legal claims, lawsuits or judgements for each healthcare provider. All Duke healthcare providers insured by Durham Casualty have a Claims History that dates back to their first day at Duke and ends at their separation from Duke. The Claims Specialist collaborates with Credentialing offices, Insurance Companies, Academic Medical Centers, Legal Departments and other providers and institutions to prepare Claims History requests. Claims Histories are prepared for DUHS healthcare providers including faculty, staff, GME trainees, students, nursing etc. and for former Duke employees, faculty, staff and students etc. Requests are received from current and former DUHS staff, faculty, students etc. and any institution where they may be affiliated or employed throughout the world. Internal Duke Claims Histories are required for clinical providers and CVO for routine re-credentialing.
Insurance Audits: The Claims Specialist is responsible for facilitating and procuring all DUHS Risk Management (Duke Health, Duke Regional Hospital, Duke Raleigh Hospital and Ambulatory Services) incident and claim files for Durham Casualty audits.
DUHS Off-Site, Volunteer, Expert Witness, Moonlighting, International, Activities: The Claims Specialist must analyze and determine applicable DCC coverage for Faculty and Staff approved Off Site, Volunteer, Expert Witness, Moonlighting, and International Activities. Consult with GME Office, Registrar???s Office, or Department Chair/Dean to confirm the validity of the TLA, TSMA or other contractual documents and obtain appropriate approvals. Track and report coverage data annually to AVP of Risk Management and Insurance Manager for Durham Casualty renewal submission.
Other: The Claims Specialist conducts various insurance related projects for the Assistant Vice President Risk Management. They must interface regularly with DUHS Leadership, Counsel's, Credentialing, PDC, and Risk Managers, Risk Management IT and Insurance Manager and numerous professionals internally and externally.
Required Qualifications at this Level
Education
Bachelor's degree required in Business Administration, Hospital Administration, or a related field. A degree in a different field combined with Professional Liability Insurance or other related experience may also be considered.
Experience
3 professional liability insurance experience.
Degrees, Licensure, and/or Certification
N/A
Knowledge, Skills, and Abilities
- Ability to communicate effectively with professionals of all levels of medicine, healthcare, academia, insurance, legal and credentialing.
- Ability to work independently without direct supervision.
- High level of critical thinking, high attention to detail and the ability to analyze complex insurance coverage situations and make coverage decisions and determinations autonomously.
- Knowledge of medical, legal and insurance terminology and the ability to navigate electronic
Distinguishing Characteristics of this Level
N/A
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
