Clinical Claims Specialist – Medical Job at Wellpath
Why Wellpath:
About this role:
Wellpath is an EOE/Minorities/Females/Vet/Disability Employer Our investment in you:
Here at Wellpath, everything that we do is about taking care of people – our patients, our staff and our partners. We are committed to making a difference by providing hope and healing to vulnerable patients in challenging clinical environments. Our talented, compassionate team thrives in an autonomous environment, is empowered and supported by education, training and the resources to practice healthcare the way it is meant to be and strives to “Always Do The Right Thing!”
About this role:
The Clinical Claims Specialist (Medical), in collaboration with claims management, quality, and compliance teams, will review, analyze, and escalate reported medical events to gauge and prevent adverse risk. Duties also include actively investigating potential, pending, or threatened litigation and complaints for purposes of risk mitigation.
What you bring to the table:
Education:
- Bachelor's degree is preferred. Health administration, management, business administration, claims management, insurance, or related field preferred.
Experience:
- 5 years in a correctional healthcare setting, hospital management, risk management, insurance, claims management, or similar experience required.
- Previously demonstrated ability and experience in providing leadership for self-directed work teams.
- Excellent written and verbal skills with strong interpersonal, communication, and conflict resolution skills.
- Experience with data management, statistics, analytics, process improvement methodology, and PC applications preferred.
- Knowledge of principles of medical/mental health record documentation.
- Patient care, legal or claims management experience is preferred..
Licenses/Certifications:
- RN preferred
- Routinely identify adverse risk through assessments, observation, trended data, inspections, committee minutes, third-party reports, attorney requests for medical records, and administrative or associate referrals.
- Monitor incident reporting system for patient harm events and unanticipated outcomes by analyzing medical records, identifying potential exposures, and escalating risk reduction methods.
- Triage and investigate incidents by collecting medical documentation from sites to analyze and escalate accordingly.
- Perform special projects that involve data gathering, preparation of reports, trend management, and escalation.
- Collaborate with staff to identify, monitor, and report on areas of risk and litigation trends.
- Report significant/high risk claims to Director of Clinical Claims Consultants, clinical operations, compliance, claims, and legal departments to determine potential liability and develop proactive strategies to address those issues.
- Coordinate litigation risk findings with CQI so that CQI can consider and enact clinical risk recommendations to address quality issues and mitigate further legal risk exposure.
Wellpath is an EOE/Minorities/Females/Vet/Disability Employer
- Medical, Dental and Vision Insurance plan options
- Time off & leave benefits
- 401K
- Tuition Reimbursement
- Parental benefits
- Perks and discounts
- And more available here https://wellpathcareers.com/
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