Job SummaryResponsible for managing a portfolio of claims including medical records reviews, claims investigation, and assessment of liability exposure and standard of care issues. Utilizes multiple data management systems including variance reporting system and Risk Management Information System (RMIS) for investigation and claims administration. Works collaboratively with risk management attorneys, outside counsel, and facility-based risk managers in claims investigation and claims resolution. Provides broad clinical risk management expertise to the organization in order to proactively address enterprise clinical risk issues and improve quality of care. Responsible for clinical risk management education in furtherance of loss prevention initiatives and in collaboration with Loss Prevention, Quality and Patient Safety functions.
Job DescriptionMinimum QualificationsEducation: Bachelor's Degree in Nursing preferred
Licenses/Certifications: Certified Professional Healthcare Risk Management (CPHRM) designation
or obtain within three (3) years of placement in role
Experience / Knowledge / Skills: - Minimum five (5) years of progressive clinical experience in a hospital setting.
- Minimum three (3) years of experience in risk management in a hospital-based environment or as a nurse paralegal in a law firm.
- Skilled in clinical education curriculum development and delivery.
- Ability to work collaboratively with health professionals at all levels to achieve established goals
- Computer proficiency.
- Demonstrated interpersonal, organizational, and communication skills.
Principal Accountabilities- Responsible for management of a portfolio of claims as assigned.
- Responsible for claims investigation, medical records review and chart summaries and timelines, liability assessment and evaluation of standard of care issues.
- Responsible for managing and resolving claims via communications with claimants, families, and counsel within approved authority limits.
- Acts as a liaison between outside counsel and the organization in development of a claim, through discovery and resolution.
- Serves as a representative of the organization as needed for mediations or at trials.
- Provides backup coverage for risk management issues as needed to support facility-based risk managers and rotates in system risk management on-call duties.
- Provides clinical risk management counsel and support to facility-based Risk Managers.
- Proactively monitors clinical claims trend data to provide appropriate loss prevention or mitigation recommendations, advice and counsel.
- Participates in proactive enterprise clinical risk assessments in collaboration with other functional areas to improve the identification of risks and to use as a basis for prioritization of risk management initiatives.
- Interfaces with insurance function as needed to assure timely notification of claims as necessary and with the loss prevention and mitigation function for continued quality improvement and risk mitigation
- Works collaboratively with loss prevention, quality and patient safety functions in the development and implementation of clinical risk management education initiatives
- Acts as a clinical risk management educational resource to the facilities system-wide including conducting needs assessments, curriculum development and delivery of clinical risk education to promote risk reduction and mitigate liability exposures.
- Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
- Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann's service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.
- Other duties as assigned
