State Risk Adjuster 1

State of Louisiana; Baton Rouge (LA); On-site; USD 52,000 - 75,000; Full time

Job summary

Patient's Compensation Fund in Louisiana seeks a capable claims professional to drive the vision of the section and manage independent judgment in medical malpractice claims. You will handle complex cases, maintain confidentiality, and work with a team to ensure accurate, timely processing.

The role requires negotiating with insurers and attorneys, applying policy rules, and using PRISM for claims processing.

Qualifications

• Competencies include following guidance, effective communication, policy adherence, sound judgment, decisive action, integrity, adaptability, professionalism, and customer focus.

Responsibilities

• Monitor the medical review panel process and update records.
• Correspond with primary insurers, defense attorneys, and outside adjusters to determine validity, exposure, and status of claims.
• Evaluate information to determine if the layer of primary coverage could be exceeded and refer cases over $100,000 to the supervisor.
• Maintain ongoing contact with assigned future medical claimants, their caregivers, vendors, and health care providers.
• Request medical reports and bills and verify relation to medical malpractice claims.
• Process payment requests, review reasonableness, and disallow unnecessary charges after senior examiner input.
• Obtain estimates to modify homes and vehicles for handicapped individuals.

Skills

Accepting Direction

Communicating Effectively

Following Policies and Procedures

Making Accurate Judgments

Acting Decisively

Ethics and Integrity

Adapting to Change

Professionalism

Focusing on Customers

Education

Bachelor's degree

Tools

PRISM software

Job description

About the Patient's Compensation Fund

The Patient's Compensation Fund (PCF) was created in 1975 to provide an affordable and guaranteed medical malpractice coverage system for the private healthcare providers in the state. The Patient's Compensation Fund is a self-funded state entity, operating independently of the main state budget, and governed by the PCF Oversight Board. The Patient's Compensation Fund provides protection for the healthcare system, keeping costs down, and providing a guaranteed pool of funds to pay those citizens injured from medical malpractice of private care providers.

We are a small agency invested to retain a skilled, productive, engaged, diverse team that we support through training and development, building connections, and supporting a harmonious work life while delivering quality services to the citizens of Louisiana.

About this Position

Incumbent will be accountable in use of independent judgment and decision-making for driving the vision and mission of this Section. Incumbent will possess financial savvy, have strong interpersonal skills, and be results oriented to successfully perform the daily operations required in this Section. Incumbent will maintain a high-level of confidentiality, be effective in professional communication skills, and independently handle complex insurance claims pertaining to individuals injured in medical malpractice cases. Incumbent receives not only specialized training in legal and medical malpractice terms for thorough understanding in the medical malpractice process, procedure, and agency-related State statute, but additionally in the PRISM software systems specialized for PCF claims processing, settlements, and payments. This position directly reports and receives supervision from the State Risk Adjuster 5 (Claims Supervisor), while working with a considerable degree of autonomy.

AN IDEAL CANDIDATE WILL POSSESS THE FOLLOWING COMPETENCIES:

• Accepting Direction: The ability to be open and willing to follow guidance or instructions


• Communicating Effectively: The ability to convey information, ideas, and emotions using structured communication methods that promote understanding and engagement.


• Following Policies and Procedures: The ability to follow, reinforce, adapt, or develop policies and procedures to maintain compliance with federal and state legal requirements, State Civil Service rules, and organizational policies.


• Making Accurate Judgments: The ability to assess options, weigh risks, and make sound decisions using available information and logical reasoning.


• Acting Decisively: The ability to make timely, confident decisions using sound reason.


• Acting with Ethics and Integrity: The ability to make choices that reflect ethical standards, integrity and honesty, regardless of circumstances or personal benefit.


• Adapting to Change: The ability to demonstrate flexibility in thoughts, behaviors, and actions in response to evolving circumstances or unexpected change.


• Displaying Professionalism: The ability to uphold workplace standards through consistent conduct, responsible communication, and consideration for others.


• Focusing on Customers: The ability to understand and meet the needs, preferences, and experiences of internal and external customers.

• Three years of experience in insurance claims adjusting, examining, or investigation; accident investigation, legal research, project management, contract management, or construction management; OR


• Six years of full-time work experience in any field; OR


• A bachelor's degree.


• EXPERIENCE SUBSTITUTION: Every 30 semester hours earned from an accredited college or university will be credited as one year of experience towards the six years of full-time work experience in any field. The maximum substitution allowed is 120 semester hours which substitutes for a maximum of four years of experience in any field.

The official job specifications for this role, as defined by the State Civil Service, can be found here.

Job Duties and Other Information

• Monitor the medical review panel process, requesting updates as necessary and making all appropriate computer entries.


• Corresponds with primary insurers, defense attorneys, and outside claims adjusters to determine validity, exposure, and status of claims. Evaluates incoming medical, investigative, and discovery information to determine if the layer of primary coverage could be exceeded, referring cases of liability and/or value over $100,000.00 to the supervisor.


• Must maintain ongoing contact with assigned future medical claimants, their caregivers, vendors, and health care providers.


• Requests medical reports and bills from treating health care providers. Reviews medical reports and claim information to verify the bill submitted relates to a medical malpractice claim and all necessary documentation has been received.


• Processes requests for payment of related charges after determining if fees are reasonable and customary and disallowing unrelated or unnecessary charges after review of suggested cuts by the senior examiner.


• Obtains estimates for work done to modify homes and to purchase and modify vehicles for handicapped individuals.

Position Specific Details

Appointment type: Probational, Promotional

Work Schedule: Monday - Friday, Overtime as needed

Compensation: This position is eligible for premium pay of up to $2.00 per hour.

All prospective new hires will be subject to employment eligibility verification via the federal government's E-Verify system.

As an Equal Opportunity Employer, PCF is committed to a diverse and inclusive workplace prohibiting discrimination based on any non-merit factor.

PCF is a State as a Model Employer (SAME) agency that supports improved employment opportunities for individuals with disabilities.