Claims Adjuster

Position Summary:

 

At Orlando Health, we are ordinary people with extraordinary individuality, working together to bring help, healing and hope to those we serve. By daily embodying our over 100-year legacy, we reinforce our reputation as a trusted and respected healthcare organization that delivers professional and compassionate care to our patients, families and communities. Through our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond.

 

ORLANDO HEALTH - BENEFITS & PERKS:

All Inclusive Benefits (start day one)

• Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.

Forbes Recognizes Orlando Health as a Best-In-State Employer

• Forbes has named Orlando Health as one of America's Best-In-State Employers for 2024. Orlando Health is the top healthcare organization in the Metro Orlando area to make the prestigious list. "We are proud to be named once again as a best place to work," said Karen Frenier, VP (HR). "This achievement reflects our positive culture and efforts to ensure that all team members feel respected, supported and valued.

Employee-centric

• Orlando Health has been selected as one of the “Best Places to Work in Healthcare” by Modern Healthcare

Position Summary

The Claims Adjuster manages a case load of third-party claims made against the organization, with a focus on medical professional and general liability claims.

Responsibilities:

Essential Functions

Identifies actual and potential third-party claims against the organization with a focus on professional and general liability claims, but may also include assistance with property, auto and other types of claims.
Responsible for the coordination of a complete investigation and evaluation of all assigned claims and works closely with assigned legal counsel and Claims leadership to develop strategy to resolve or defend the claim.
Utilizes claims management and loss reduction techniques in negotiating and settling claims that can be resolved without legal counsel involvement.
Participates in setting initial reserves and making recommendations for changes to reserves on all assigned claims in conjunction with the Claims leadership.
Responsible for establishing and maintaining claim files with detailed documentation of all significant claims’ activity and correspondence with legal team and insurance carrier.
Achieves an open trusting relationship with and acts as a liaison between Orlando Health team members, physicians and assigned legal counsel from initiation of claim through settlement and/or trial.
Coordinates activities for each claim with assigned legal counsel including interpretation of medical records, retention of experts, facilitating discovery, performing research, and scheduling of depositions. Attends all depositions involving Orlando Health physicians, residents and team members.
Attends mediation for all assigned claims. At times, attends mediation as the representative for Orlando Health as directed by Claims leadership with an agreed authority to settle the claim.
Fully participates in trial activities to include focus groups, witness preparation, development of trial exhibits, and attendance at trial.
Responsible for managing Department of Health licensure investigations involving employed physicians and team members in conjunction with assigned legal counsel. Acts as a liaison between Orlando Health physicians/team members and assigned legal counsel and assists with formulating response to the DOH. Attends board meeting of licensing agency with physician or team member and legal counsel if a settlement agreement is reached with the board.
Reviews all legal bills and other invoices for compliance with litigation plan and approves for payment.
Prepares and updates reports on all assigned claims that demonstrates strategy for resolution.
Attends and participates in internal claims team meetings, scheduled attorney meetings, claims strategy meetings and pre-mediation meetings.
Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
Maintains compliance with all Orlando Health policies and procedures.

 

Other Related Functions

Acts as a resource for the Risk Manager, Prevention in early resolution of potential claims.
Assists in maintaining evidence in any potential claim.
Archives retired policies/procedures and other related materials
Facilitates external peer review as needed.
Works with other Orlando Health departments regarding insurance activities including property surveys, safety programs, requests for COI’s and claims histories.
Participate in claims education to Orlando Health team members, physician groups and residency programs when requested.

Qualifications:

Education/Training

Bachelor’s degree in healthcare (preferred), business or closely related field.

 

Licensure/Certification

None.

 

Experience

Five (5) years of clinical, medical-legal or claims adjusting experience.