Director Claims Management

Health First; Florida; On-site; USD 120,000 - 180,000; Full time

Job summary

Health First in Florida seeks a Director, Claims Management to oversee investigation, evaluation and resolution of medical, professional, and general liability claims, applying clinical judgment in line with Health First’s guidelines and best practices.

You will lead collaboration with outside counsel, inform reserve decisions, manage reporting, audits, and trend analysis to support clinical risk management and patient safety initiatives.

Qualifications

• Clinical expertise required, nursing background or clinical risk management experience.
• Understanding of hospital operations, medical charts, clinical terminology; strong communication and business skills.

Responsibilities

• Oversee investigation, evaluation and resolution of medical, professional, and general liability claims.
• Collaborate with outside counsel and Claims Reserve Committee to develop strategic frameworks for claim resolution.
• Manage claims reporting requirements, audits, and analyze trending information to support risk management and patient safety initiatives.

Skills

Clinical risk management

Nursing background

Hospital operations

Communication skills

Education

Bachelor's degree in Risk Management, Legal Studies, Nursing (BSN)

Master's degree in Legal Studies, Risk Management, Nursing or Juris Doctor (JD)

RN licensure in Florida

Tools

AIC

CPHRM

ARM

Paralegal Certification

Job description

• The Director, Claims Management oversees the investigation, evaluation and resolution of medical, professional, and general liability claims, applying clinical judgment to standard–of–care and causation analysis in alignment with Health First’s claims guidelines and best practices.
• The Director, Claims Management reports to the Vice President, Claims & Risk Financing and, in collaboration with outside counsel and the Claims Reserve Committee, develops strategic frameworks for the resolution of claims and lawsuits, working closely with medical staff and clinical leadership to evaluate case merit and inform reserve decisions.
• The Director, Claims Management, manages claims reporting requirements and claims systems, coordinates audits, and analyzes trending information to support clinical risk management and patient safety initiatives.

MINIMUM QUALIFICATIONS

• Clinical expertise is the highest priority, ideally from a nursing background or significant clinical risk management experience
• Candidates must understand hospital operations, medical charts, and clinical terminology, alongside possessing strong communication and business skills.

Education:

Bachelor's degree in Risk Management, Legal Studies, Nursing (BSN), or relevant field.

Work Experience:

• Three (3) years' experience managing professional and general liability claims for a hospital system, insurance carrier, self–insured environment, or a law–firm setting, or similar combination, with healthcare or clinical claims experience preferred.

Certification:

Any one of the following within two (2) years of start date and maintained:

• Associate in Claims (AIC) or
• Certified Professional in Healthcare Risk Management (CPHRM) or
• Associate in Risk Management (ARM) or
• Paralegal Certification OR Other related certification.

PREFERRED QUALIFICATIONS

Education:

Master's degree in Legal Studies, Risk Management, or Nursing (MSN) OR Juris Doctor (JD).

Work Experience:

• Five (5) to seven (7) years' experience managing professional and general liability claims for a hospital system, insurance carrier, self–insured environment, or a law–firm setting, with healthcare or clinical claims experience preferred.
• Experience presenting case evaluations and settlement recommendations to a Claims Reserve Committee or comparable peer review body preferred.
• Experience collaborating with medical staff, peer review, or quality committees on standard–of–care assessments preferred.

Licensure:

Registered Nurse (RN) licensure in the State of Florida or endorsement.

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.