Claims Adjuster I, Risk Management, Winston Campus
Job description
JOB SUMMARY:
Ensures that each claim file includes all necessary information/documentation before completing the closing process. Works closely with Patient and Family Relations and Patient Safety to address concerns/complaints related to the care and services provided, as well as the overall patient experience. Acts as a professional liaison between the department and its internal and external customers to gather information and reduce the potential for future risks to the Medical Center.
EDUCATION/EXPERIENCE:
Bachelor's Degree and three years' risk management, insurance claims or administrative experience required; or, an equivalent combination of education and experience.
LICENSURE, CERTIFICATION, and/or REGISTRATION:
North Carolina State Adjuster License required.
ESSENTIAL FUNCTIONS:
- Analyzes and obtains the information necessary to document the claim in accordance with Medical Center policy, jurisdictional regulations, NC Fair Claims Handling Act, and identifies opportunities for improvement.
- Investigates patient incidents and all in-house medical emergency incidents (Code 44s) at the time of the occurrence or after the fact.
- Responsible for contacting claimants and involved parties, and investigates, negotiates, and adjusts claims within the guidelines of the NC Fair Claims Handling Act and departmental protocols.
- Collects and compiles data, statistics and materials for reports and projects; prepares and edits written materials using the appropriate computer processing skills.
- Establishes rapport with staff, faculty, patients, visitors, and families to maximize risk prevention and minimize risk exposure.
- Responsible for the initial medical record review of events identified to determine whether Risk Management should investigate further.
- Performs other projects and assignments as directed.
- Adheres to the general hospital standards to promote a cooperative work environment using communication skills, interpersonal relationships and team building.
- Serves as a resource to Medical Center staff and faculty on risk management issues in order to minimize risk exposure and enhance departmental relations.
- Develops open line of communication with patients and their families in crises in order to mitigate loss exposure.
SKILLS/QUALIFICATIONS:
- Strong interpersonal and customer service skills
- Word processing experience using Word, Excel, outlook and other database software
- Ability to type 30 WPM
- Demonstrates a working knowledge of claim systems and claim industry
- Professional phone etiquette
- Ability to resolve conflicts
- High degree of initiative, mature judgment and discretion
- Ability to handle confidential information without disclosure
- Flexibility in a changing work environment
- Working knowledge of medical terminology
WORK ENVIRONMENT:
- Medical administrative environment
- Clean, well-lit, comfortable climate
- Subject to many interruptions
- Fast-paced, continually changing environment
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