Claims & Risk Analyst

Advocate Health; Oak Brook (IL); On-site; USD 90,000 - 120,000; Full time

Job summary

Advocate Health seeks a skilled RMIS and claims management professional to lead oversight, development, and maintenance of the RMIS database and related reporting. The role emphasizes data standardization, BI reporting, and collaboration with site risk management to identify risk reduction opportunities across Advocate sites.

You will manage reserves, coordinate with claims leadership, and ensure timely reporting while working with defense counsel and vendors.

Qualifications

• Bachelor's degree or equivalent work experience is required.
• Strong written and verbal communication skills.
• Proficiency with MS Office tools and data reporting.
• Ability to interpret data and present findings clearly.

Responsibilities

• Provide lead oversight and development of RMIS database and reporting features.
• Analyze tracking and trends in loss data; prepare quarterly and annual statistical reports.
• Coordinate with site Risk Management and Director of Claims on risk reduction opportunities.
• Collaborate with RMIS vendor to tailor BI reports and data insights.
• Manage reserves and settlement decisions within authority limits.
• Prepare loss runs for reporting to captives, brokers, and reinsurers as needed.
• Oversee claim activities and ensure timely reporting and compliance with guidelines.

Skills

Computer literacy

Communication skills

Telephone etiquette

Organizational skills

Education

Bachelor's degree or equivalent experience

Tools

Word

PowerPoint

MS Outlook

Excel

Job description

Major Responsibilities:

Provide a lead role in oversight, development and maintenance of RMIS database, adhering to department claims management guidelines and procedures and standardizing collection and input of claims/litigation data.

• This includes management, functionality, enhancements, upgrades and reporting features, including business intelligence reporting, oversight of CMS reporting to TPA compliance
• Conduct analysis of tracking and trending loss information, and preparing statistical analysis of data and graphs for all Advocate sites on a quarterly and annual basis.
• Claims analysis and statistical interpretation will be coordinated with the respective site Risk Management personnel and with the Administrator, Risk Management, and the Director of Claims to identify opportunities for risk reduction, patient safety and process improvements.
• Work closely with the RMIS vendor on developing Business Intelligence Reports, customization of reports and system functionality to achieve the insight needs to dynamically manage our risk, insurance and claims programs.

Manage, monitor and review designated general and professional liability claims with maximum case exposure not to exceed $250,000.

• Perform case assessment, identify potential damages analysis; establish timely reserves and adjust reserves on all assigned claims, attorney liens and lawsuits within designated authority level.
• Establish and meet KRA strategic goals for the position and in alignment with departmental and Company goals.
• Advise stakeholders of changes in reserves and provide explanations of reserve changes to claims, insurance, risk management and accounting.
• Provide updated comprehensive reports and analysis of pending cases and makes recommendations to the Director of Claims of cases which exceed the Claims/Risk Analyst’s authority.
• Negotiate and resolve by way of settlement all assigned claims, attorney liens and lawsuits up to $150,000 or such amounts as authorized by the Director of Claims, this includes negotiation with plaintiff’s attorneys, claimants and patients and their family members when applicable.
• Manage and monitor claim activities, including the management of defense counsel through all aspects of litigation. Ensure and track timely reporting and compliance with Advocate’s Litigation Management Guidelines by defense counsel.
• Review, adjust as indicated, and approve defense attorney bills and litigation vendor invoices
• This position will serve as AISPC’s official representative at site meetings, mediations, pre-trials and trials, present the Company’s position on pre-litigated or litigated matters including the responsibility of presenting and negotiating financial settlement authority for the Company.

Identify loss exposures for the System and at the site level, identify patient safety issues and make recommendations to minimize, reduce and/or eliminate risks or harm by way of cost-effective approaches as identified throughout the handling of all assigned claims and litigation.

• Act as primary point of contact for business partners in resolving and addressing routine legal and claim matters. For example, billing matters, subpoenas for depositions, IDFPR and IDPH inquiries. Comply with all reporting requirements of the NPDB and IDFPR as required.
• Act as a primary resource with oversight responsibility for any additional projects as assigned.
• Provide daily direction to assigned site risk/claims management personnel as needed and within delegated authority levels.
• Oversee information gathering and investigations by Site Risk Management personnel. Participate in adjunct claims review assessments and meetings and make recommendations to the claims committee members for all claims and litigation.
• Serve as a resource and provide guidance and oversight for discovery completion and with the preparation of witnesses and expert testimony with respective sites.
• Manage, track, prepare and present ad hoc and analysis reports summarizing liability litigation matters, including general liability, subrogation matters, mediations and arbitrations and all other claims.
• Conduct detailed research and analysis on legal issues when applicable, and as assigned.

Provide a lead role in the oversight of attorney vendor invoices and litigation vendors through the accounting OnBase system and integration with the RMIS database for all claims and litigation.

• Oversee the maintenance of system coordination for financial uploads for tracking and tabulating payments and expenses on all claims and litigation.
• Perform reconciliation of payments assessments with the Finance Department.

Provide a lead role in the timely reporting of claims and the management of the loss data under Advocate SPC.

• Responsible for the preparation of loss runs on a semi-annual and annual basis for the timely reporting of claims to captive, brokers, insurers and reinsurers and maintain appropriate documentation of the reporting of those claims.
• Prepare loss data and information for annual actuarial reviews and excess reporting.
• Gather and provide loss information to underwriters, Internal Audit and external auditors, and as needed to actuaries.

Coordinate educational programs and in-services on medical/legal issues at designated Advocate sites.

• Such risk and claims management programs are designed to educate and teach clinical staff how to reduce or eliminate risk. These educational programs will be correlated to frequency and severity of claims and trended loss information.

• Oversee, evaluate and assign incoming Subpoena Requests for all employed medical care providers.
  Assess and confirm applicable insurance coverage and assign defense counsel to provide the deponent (s) with assistance.

Licensure, Registration, and/or Certification Required:

• None Required.

Education Required:

• Bachelor Degree or equivalent experience.

Experience Required:

• A minimum of 3-5 years experience preferred as an insurance claims adjuster, third party claims administrator, or litigation support specialist, with experience handling litigated general and professional liability claims matters, evaluating reserves, and facilitating case resolution.
• 5 years in health care environment, insurance, legal, risk management. Enrollment in Paralegal Certificate Program or Course Work related to job.

Knowledge, Skills & Abilities Required:

• General knowledge of computer applications
• Proficiency in the following software: Word, Power Point, MS Outlook, Excel. Communication, verbal, narrative, written and skills.
• Telephone etiquette skills. Customer focused and Organizational skills.

Physical Requirements and Working Conditions:

• Organizational skills and ability to function independently required.
• Excellent spelling, grammar, and punctuation required.
• Ability to work under pressure and to handle confidential materials is essential.
• Must have good concentration skills and the ability to judge priorities.
• Project management skills a plus.
• Fast-paced environment with established time constraints.
• Ability to flex schedule as necessary.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.