Director Claims Management

About the role

The Director, Claims Management oversees the investigation, evaluation and resolution of medical, professional, and general liability claims, applying clinical judgment to standard-of-care and causation analysis in alignment with Health First's claims guidelines and best practices. The Director reports to the Vice President, Claims & Risk Financing and, in collaboration with outside counsel and the Claims Reserve Committee, develops strategic frameworks for the resolution of claims and lawsuits, working closely with medical staff and clinical leadership to evaluate case merit and inform reserve decisions. The Director also manages claims reporting requirements and claims systems, coordinates audits, and analyzes trending information to support clinical risk management and patient safety initiatives.

Responsibilities

• Oversee investigation, evaluation, and resolution of medical, professional, and general liability claims
• Apply clinical judgment to standard-of-care and causation analysis per Health First's claims guidelines and best practices
• Develop strategic frameworks for resolution of claims and lawsuits in collaboration with outside counsel and the Claims Reserve Committee
• Work closely with medical staff and clinical leadership to evaluate case merit and inform reserve decisions
• Manage claims reporting requirements and claims systems
• Coordinate audits and analyze trending information to support clinical risk management and patient safety initiatives

Requirements

• Clinical expertise is the highest priority, ideally from a nursing background or significant clinical risk management experience
• Understanding of hospital operations, medical charts, and clinical terminology, alongside strong communication and business skills
• Bachelor's degree in Risk Management, Legal Studies, Nursing (BSN), or relevant field
• Three (3) years' experience managing professional and general liability claims for a hospital system, insurance carrier, self-insured environment, or law-firm setting (healthcare or clinical claims experience preferred)
• One of the following certifications within two (2) years of start date and maintained:
  • Associate in Claims (AIC)
  • Certified Professional in Healthcare Risk Management (CPHRM)
  • Associate in Risk Management (ARM)
  • Paralegal Certification
  • Other related certification

Preferred Qualifications

• Master's degree in Legal Studies, Risk Management, or Nursing (MSN) OR Juris Doctor (JD)
• Five (5) to seven (7) years' experience managing professional and general liability claims for a hospital system, insurance carrier, self-insured environment, or law-firm setting (healthcare or clinical claims experience preferred)
• Experience presenting case evaluations and settlement recommendations to a Claims Reserve Committee or comparable peer review body
• Experience collaborating with medical staff, peer review, or quality committees on standard-of-care assessments
• Registered Nurse (RN) licensure in the State of Florida or endorsement

About Health First

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.