Remote Medical Claims Processing Jobs in Michigan

 ** Position allows for work remote/work from home.

ESSENTIAL FUNCTIONS: 

General Management Responsibilities: 

• Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision and Values of Trinity Health in behaviors, practices, and decisions. 

• Ensures adherence to Trinity Health Insurance and Risk Management Services (IRMS) Policies and Procedures.   

• Complies with Best Practice protocol in management of assigned claims. 

Claim Management Responsibilities: 

• Reviews new incidents as assigned and opens claims as needed.  Assesses coverage of all potential Trinity Health insured and obtains formal coverage analysis if indicated.   

• Formulates and implements a thorough investigation plan for each claim.  Evaluates claim with respect to standard of care, liability, causation, and damages. Considers witness credibility and expert opinions and determines the value of the claim.  

• Establishes and completes timely review of indemnity and expense reserves 

• Participates in the management of uninsured litigation across the system, as assigned. 

• Determines claim resolution strategy (including trial) and obtains required settlement authority per Settlement Authority Matrix.  Adhering to delegated authority limits, negotiates or directs the negotiation of the claims/lawsuit to resolution. 

• Notifies excess insurer of claims according to established criteria and provides file updates pursuant to reporting guidelines. 

• Maintains a diary system to monitor all open claims.  Updates claim files per Best Practice Protocol. 

• Ensures adherence to IRMS Legal Hold policy. 

• Participates in Regional Claims Review and Large Loss meetings to ensure matters are presented consistent with the applicable policy.   

• Represents Health Ministry/Trinity Health in participating in case evaluations, settlement conferences, facilitations, mediation, and trials. 

• Retains approved defense counsel on a per claim basis.  Directs and supervises the work of outside defense counsel pursuant to the litigation protocol.  Reviews and responds to attorney reports and recommendations as appropriate.  Reviews and approves the defense counsel fee and litigation expenses and adherence to preferred vendor use. 

• Responsible for compliance with Medicare reporting requirements. 

Other Responsibilities: 

• Works collaboratively with Loss Control Directors to identify risk management trends, issues, and opportunities. 

• Keeps IRMS management apprised of significant case developments, as appropriate. 

• Directs and supervises Claims staff in maintaining and updating Clearsight database.  

• Ensures adherence to NPDB and State reporting requirements. 

• Communicates with Health Ministry (HM) Risk Management/Patient Safety colleagues relative to all aspects involving claims management. 

• This includes: 

• Communication related to new matters, and potential exposure; 

• Preservation of evidence, documents, electronic data as needed; 

• Unsupportive reviews, or other significant case development as needed; 

• Requests for authority and risk modifications as required per procedure; and 

• Adherence to protocols (venue specific) for protected documents involved in litigation. 

• Serve as liaison for HM senior leadership relative to pending matters and potential exposure. 

• This includes: 

• Requests for authority per Settlement Authority Matrix; 

• Provides updates as needed regarding high exposure claims; 

• Advises as to high profile/media sensitive matters; and 

• Provides comprehensive claims review as requested for RHM senior leadership. 

• Develops individual goals in conjunction with Claims Department goals.   

• Attends and participates in regularly scheduled Team and Department meetings. 

• Reviews monthly ClearSight reports for accuracy, data integrity and reserve assessment.   

• Participates in IRMS and/or Trinity Health committees as requested by the Director of Liability Claims to provide subject matter expertise. 

• Maintains awareness of existing and proposed legislation, court decisions and emerging trends in claims litigation specific to the Team’s venue.  Recommends process and/or procedure changes as appropriate. 

• Maintains a working knowledge of applicable Federal, State, and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior. 

• Bachelor’s degree in a related field, or an equivalent combination of education and experience is required.  A clinical health care degree and/or graduate degree in law or hospital administration are preferred.   

• Three (3) to five (5) years of experience as a liability claims professional adjuster, defense malpractice attorney or hospital risk manager is necessary.  Supervisory experience preferred. 

• Advanced knowledge and working relationships in risk management, quality management and improvement is helpful. 

• Proficiency in the use of IRMS claim database (Clearsight). 

• Working knowledge of medical terminology is 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. 

• Ability to meet deadlines and respond to shifting priorities is necessary.  Must be comfortable operating in a collaborative, shared leadership environment. 

• A personal presence which is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health is essential. 

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS 

• Must be able to travel to the various Trinity Health sites if/when needed.

• Must be able to work independently at a remote location. 

• Must be able to adapt to frequently changing work priorities as well as work under pressure.  

• Must be able to perform moderate physical activity, lifting and bending. 

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.   They are not to be construed as an exhaustive list of duties so assigned. 

Hourly pay ranges: $50.80 - $83.81

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.