Management Medical

CLAIM MANAGEMENT: Claim Consultant; Claim Specialist; Risk Manager

Summary of Qualifications: Ten years of progressively responsible

experience in medical malpractice

claims. Twelve years clinical experience. Conceptual and anticipatory skills

with the proven ability to think outside the box. Ability to quickly

identify,

analyze and evaluate problems and recommend solutions. Ability to resolve

complex claims through investigation, evaluation and disposition.

Professional Experience :

Claims Management Consultant

Bender, Inc. Lead a claim management program for self-insured

Wixom, MI hospitals and physicians.

11/2005 - 7/2008

Handled a portfolio of client relationships with a

caseload of hospital professional liability, physician

professional liability, and general liability from the

investigation of the claim through resolution;

Evaluated losses with respect to liability, causation,

and damages; Determined exposure, established adequate

reserves and made timely adjustments as required;

compiled cash flow analysis;

Liaised with risk retention groups domiciled in the

Cayman Islands; Responsible for annual contract renewals

valued at over $450,0000;

Oversight of revenues up to $4 million dollars; Client

base was in MI, CT, RI, NY, and MT;

Presented claim information on high exposure losses at

quarterly Board meetings;

Audit open claims on a quarterly basis; Collaborated

with risk managers, and defense counsel regarding risk

control programs and patient safety to prevent losses

and reduce premiums;

Determined settlement value of the loss and negotiated

proper settlement of claims within authority.

Documents clearly and concisely all relevant activity on

assigned files and makes recommendations for additional

activity as appropriate;

Trained less experienced claim representatives.

Oakwood Hospital Claims Representative

And Medical Center Oversight of corporate claims for a teaching

Dearborn, MI hospital and TPA.

2/1999 - 10/2005

Handled a caseload of hospital professional

liability, physician professional liability, and

general liability losses from investigation of the

claim through resolution;

Presented claim information on high exposure

losses to claims committee monthly;

Developed and implemented processes for trend

analysis;

Interpreted complex or unusual policy coverage and

determined if coverage apply to claims submitted;

Directed defense counsel in the handling of

litigated cases; Conducted claim audits with

defense counsel and TPA quarterly;

Evaluated losses with respect to liability,

causation, and damages;

Negotiated settlements within authority limits;

Familiar with The Joint Commission's regulatory

and accreditation processes.

United American Utilization Review Coordinator

Healthcare Conducted telephonic clinical reviews and applied

Corporation appropriate criteria based on intensity of service and

Detroit, MI severity of illness;

4/1993 - 11/1998

Confirmed services provided were clinically appropriate

and in the appropriate setting;

Assessed the stability of patients requiring transfer

and assist with the transfer process to ensure safe and

timely transfer to appropriate facility for out of plan

admissions or cases in need of higher level of care;

Reviewed medical records for quality of care/service

issues;

Communicated with members/providers regarding health

outcomes;

Familiar with and worked within the guidelines of MDCH

and NCQA regulatory and accreditation processes.

Education:

Bachelor of Science 2002

University of Detroit Mercy

License:

Emergency Medical Technician 1991-2003

Michigan Department of Community Health

Professional Affiliations:

Michigan Society of Healthcare Risk

Management

American Society of Healthcare Risk

Management

Contact this candidate