Claims Examiner

Job No: 536962

Work Type: Full Time

Location: Alachua

Categories: Allied Health, Office/Administrative/Fiscal Support, Legal/Audit Services/Compliance

Department: 27030000 - HA-SELF INSURANCE TRUST FUND

Job Description

Classification Title: Claims Examiner

Classification Minimum Requirements: Bachelor's degree in an appropriate area and four years of relevant experience; or an equivalent combination of education and experience.

Intake, process, and dispose of all incidents reported and/or referred to the SIP. Pursuant to Rule 6C-10.001, Regulations of the Florida Board of Governors, responsible for establishing incident reporting procedures to be followed by the various units of the HSC and other SIP participants. Ensure all reported incidents are reviewed and evaluated for patient care and health care delivery improvement opportunities and for potential claims falling under the purview of the SIP, including, (but not limited to) being available (on a direct access basis) to take incident reports, ensuring that reported incidents are promptly and accurately recorded in the Claims database; performing all interviews, records reviews, and information analysis necessary to determine the chronology of events and resulting outcomes of an incident, and ensuring that appropriate administration at SIP is timely notified of significant incidents in order those incidents to be reviewed by the Director and when appropriate, timely reported to the administration of the affected SIP participant(s). Participants, with whom the incumbent will have daily contact include, (but not limited to) faculty members, staff members, and administrators of:

• UF Colleges of Medicine, Dentistry, Pharmacy, Nursing, Veterinary Medicine (including the Veterinary Medicine Teaching Hospital (VMTH)), Health-Related Professions and their affiliated facilities and programs throughout the State of Florida,
• Shands Jacksonville Medical Center and its affiliated facilities
• Shands at UF and its affiliated facilities
• Florida State University (FSU) College of Medicine and its affiliated facilities and programs throughout the State of Florida
• University of Central Florida (UCF) College of Medicine and its affiliated facilities and programs throughout the State of Florida
• Florida Atlantic University (FAU) College of Medicine and its affiliated facilities and programs throughout the State of Florida
• Florida International University (FIU) College of Medicine and its affiliated facilities and programs throughout the State of Florida

Identify, investigate, analyze, and evaluate the medical, legal, and fiscal issues related to covered claims (potential or asserted) against participants of the SIP. Responsible for the identification, review, investigation and analysis of claims (potential or asserted) against SIP participants, including (but not limited to) conducting a full factual investigation of assigned claim files; evaluating claims in terms of negligence, causation, and compensable damages; presenting initial claims summaries to SIP internal committees; making indemnity and allocated loss expense reserve recommendations pursuant to established protocols; serving as advisor to and investigator for the SIP council and its Claims and Litigation Committee; and providing such assistance as required in fulfilling SIP administrative responsibilities, including the presentation of claims summaries and related reports.

Coordinate, manage, and resolve all covered claims without Notice of Intent, potential or asserted, against SIP participants: Responsible for the management and resolution, including denial, settlement or defense of all assigned covered claims, potential or asserted, against entities and individuals protected by the SIP, including (but not limited to) negotiating directly with claimants to resolve meritorious matters without the necessity of litigation, managing the denial of claims without merit up to Notice of Intent, and collaborating with assigned Litigation staff for transition of claims that receive legal interest.

Identify risk factors that cause or contribute to claims and suits. Responsible for coordinating and ensuring that assigned files are reviewed and analyzed for potential loss prevention activities and that assigned files contain appropriate documentation pertaining to loss prevention and risk reduction initiatives associated with the claim, including (but not limited to) collaborating directly with the SIP Loss Prevention staff to identify potential risks and opportunities for loss reduction, recommending activities to mitigate or remove identified risk factors, and assisting in follow-up on loss prevention programs; providing advice and assistance on an immediate access basis regarding patient care liabilities and protocols related to loss prevention; conducting in-service education programs, seminars, and topical presentations for faculty physicians, residents, nurses, or other healthcare providers; developing loss prevention awareness through regular interactions with the healthcare providers; and demonstrating the benefits of established loss prevention programs and successful effort resulting from the proactive management of potential risks.

Coordinate effort with the SIP's Loss Prevention staff to mitigate or remove identified risk factors. Responsible for ensuring the appropriate referral to the Associate Director for Risk Management and Loss Prevention of incident reports involving patient care and health care delivery improvement, or statutory or regulatory reporting, including (but not limited to) assisting in the implementation of medical/legal professional liability risk management functions performed by the SIP in furtherance of SIP's contractual risk management responsibilities; and providing advice and assistance on an immediate access basis regarding patient care liabilities and protocols related to risk management. Attend Morbidity and Mortality Conferences, Quality Management Committees, and Code 15 Committee proceedings (as assigned), and participate in Root Cause Analysis Meetings.

Travel, including (but not limited to) going to out-of-town insured facilities and investigating incidents and meeting with involved healthcare providers.

Provide investigative and administrative management in support of healthcare providers subjected to administrative proceedings related to their medical license and facilitates the procurement of legal counsel for these providers.

Provide all services described within this position description on behalf of the other SIPs or other similar programs, while the other SIPs or other similar programs' claims and litigation processes are managed by the SIP.

Provide such other duties and functions as may be assigned. Prepare witnesses employed or formerly employed by covered entities for unsworn statements in pre-suit discovery, and represent covered entities at unsworn statements and depositions, in those situations and circumstances where prior approval has been obtained from the Claims Officer, Claims and Litigation (if licensed to practice law in the State of Florida). Perform a variety of legal work, including (but not limited to), preparing memos of law, legal responses, and witnesses before trial; conduct legal research (if attorney).

Expected Salary: Commensurate with education and experience.

Required Qualifications: Bachelor's degree in an appropriate area and four years of relevant experience; or an equivalent combination of education and experience.

Preferred: Knowledge of health care systems and medical-legal techniques desired, as is the ability to perform under great pressure in a multi-tasking environment. Must have excellent oral and written communication skills, good native intelligence, and an ability to interact with individuals of all social and economic backgrounds. Demonstrated competency in medical research and internet research skills is preferred.

Special Instructions to Applicants: In order to be considered, you must upload your cover letter and resume.

Health Assessment Required: No.

Applications Close: 12 September 2025