Claims & Risk Analyst

600 Advocate Health, Inc.; Oak Brook (IL); Hybrid; USD 45,000 - 68,000; Full time

Benefits offered by this job

Health benefits

Paid time off

Retirement plan with employer match

Educational assistance

Job summary

Advocate Health is seeking a Claims & Risk Analyst to lead RMIS database oversight, standardize data input, and ensure adherence to claims management guidelines across sites.

You will analyze loss data, prepare quarterly and annual reports, coordinate BI reporting with the RMIS vendor, and manage reserves. This role supports litigation activities and collaborates with defense counsel as needed.

Qualifications

• Bachelor degree or equivalent experience required.
• 3–5 years in insurance claims, claims admin, or litigation support preferred.
• Strong analytical and data reporting skills.

Responsibilities

• Oversee RMIS database development and data input per guidelines.
• Conduct analysis of tracking and loss information; prepare reports.
• Coordinate BI reporting with RMIS vendor for insights.
• Manage reserves and oversee claims and litigation activities.

Skills

Communication

Proficiency in MS Office

Data analysis

Attention to detail

Verbal and written skills

Education

Bachelor Degree or equivalent experience

Tools

Word

PowerPoint

MS Outlook

Excel

Job description

Department: 11219 Enterprise Corporate - Claims & Insurance Status: Full time Benefits Eligible: Yes Hours Per Week: 40 Schedule Details/Additional Information: Full Time, Dayshift Monday - Friday. This position will mostly be remote with some need to assist in local travel to court, mediations, etc Remote work is currently only approved for residents living in the following states: AL, AK, AR, AZ, DE, FL, GA, IA, ID, IL, IN, LA, KS, KY, ME, MI, MO, MS, MT, NC, ND, NE, NH, NM, NV, OH, OK, PA, SC, SD, TN, TX, UT, VA, WI, WV, WY. Non-approved needs to be approved before an offer is extended. Pay Range: $33.05 - $49.60

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.

Our Commitment to You

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.

About Advocate Health

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities.

Reshaping Access

What is access? It’s offering more sites of care than any other health system in the Midwest. But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it

Inspiring Professionals

With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities.

Transforming Care

We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care