Risk Management Specialist, Advocate Children's Hospital

Assists Manager in the daily operation of the Risk Management Program at Advocate Site. Performs the Risk Management and Claims Management related functions including the identification and evaluation of areas of risk and liability exposure and the planning and implementation of risk reduction strategies. Performs claims activities including the review and investigation of events, major occurrences, claims, patient complaints, attorney liens, and lawsuits. Interfaces with Management, Medical Staff, Health Information, Workers' Compensation, Infection Control, Quality Management, Patient Safety, Patient Relations, as well as all clinical and non-clinical departments involved in the health care delivery system. Focuses on loss prevention strategies, risk reduction strategies improving health outcomes. Provides Risk Management consultation services and conducts educational programs as delegated by Director or Manager Risk Management.

Major Responsibilities:

• Supports the adverse event reporting process (patient, visitor, public safety & facility related) via the Risk Management database, and the investigation of those adverse events to improve quality of patient care & health outcomes, promote safety and reduce of liability exposures.
  • Follows the process for reporting and review of events as in compliance with Advocate Policy. Reviews all submitted event reports. Identifies events that require claims notification and referral for further quality or peer review to Patient Safety, Quality and/or Peer Review Committees in coordination with the Manager.
  • Provides education and training to all associates, and physicians on use of the electronic event reporting system and routinely as changes and updates occur.
  • Analyzes the risk data received through event forms, anonymous reporting, telephone referrals and personal contacts. Makes corrections of event form data elements in the database for accurate, complete and consistent information.
  • Notifies Manager, Director and/or Administrator of significant serious events and may participate in the activation of the Serious Safety Event Response team.
  • Creates and generates event summary reports that identify trends, analysis, liability exposures for committees, departments/units and managers.
  • Assists in tracking medical device and equipment recalls and reviews site response plan. Adheres to the processes to sequester and maintains chain of custody of supplies, equipment & devices involved in adverse events and reports to FDA Med Watch when required.
  • Collaborates with Public Safety and Security department to identify risk and safety exposures to the Site, patients, visitors and associates and makes sure that safety and security incidents are appropriately reported and investigated. Responds to specific emergency codes at the site as appropriate.
• Performs the Claims Management and Insurance responsibilities of the Risk Management Department in compliance with Advocate policy. Supports defense legal counsel and claims administrators in the investigation and management of claims.
  • Identifies and reports to Claims Administrator incidents, accidents and events that could lead to financial loss, including professional and general liability (non-asserted claims). Conducts the investigations and follow-up, including medical record summaries, Interviewing involved staff, resident or physician and reviewing key documents. Adheres to procedures that protect sensitive and financially damaging information from inappropriate disclosure.
  • Works with non-Hospital risk management departments and the assigned claims administrators, to coordinate claims investigation and reporting for an physicians or clinicians covered by the self- insured trust at the Hospital.
  • Attends court during pretrial and trial situations as a site representative as assigned.
  • Timely reports all non-asserted, asserted, attorney liens and lawsuits to Advocate Insurance Segregated Portfolio Company (AISPC) through the Claims Administrator including the completion of all required documents and forms within the designated timeframe.
  • Adheres to requirements under CMS section 111- Mandatory Insurer Reporting and claims management guidelines.
  • Collects information and documents necessary to prepare for the defense of claims and lawsuits. Assists defense legal counsel in accessing the site records, associates, and physicians as appropriate, during the discovery process of cases in litigation. Arranges and schedules attorney interviews and depositions for defendant associates and physicians.
  • Assists Manager in collecting site and physician exposure data for the completion of the annual professional liability insurance renewal submission.
  • Assists Manager, Claims administrator and/or Legal in responding to non professional liability subpoenas or court orders. Evaluate attorney request for records to identify potential claims.
• Responsible for daily activities within the site Risk Management program through event review, risk identification, loss prevention, claims management to improve the quality of patient care, reduce risk, and minimize potential loss in compliance with Advocate Policy and department expectations.
  • Displays a proactive approach to Risk Management.
  • Provides consultation to site departments on risk management, safety issues or liability exposures under the supervision of the Manager. Identifies concerns with compliance to accreditation & regulatory risk management and patient safety standards.
  • Participates in the resolution of site operational challenges. Identifies physician and department manager concerns requiring risk management resources.
  • Implements risk identification procedures to avoid, reduce or minimize risk.
  • Serves as a resource, in coordination with Risk Manager, for the medical and legal inquiries of physician, nurses, clinicians and manager regarding patient care issues and loss prevention and/or control. Participates in the resolution of treatment issues, including but not limited to patient decisions made against medical advice (AMA), refusals of treatment, consent issues, surrogate decision-making, privacy concerns, and bioethical issues.
  • Identifies situations which may involve the disclosure of unanticipated outcomes and adverse patient safety events according to Advocate policy with involvement from the Risk Manager.
  • Participates in cause analysis, other quality improvement (FMEA, LEAN, VSA, RIE) or quality review activities as assigned and identifies opportunities for improvements and risk reductions strategies. Participates in health outcomes initiatives by compiling data and identifying trends for department managers, medical staff, nursing department and other departments.
  • Participates in site committees, as assigned, to promote safety, improve health outcomes and support organizational risk reduction.
  • Assists with Proactive Risk Assessments of high risk clinical and facility areas and follow up on implementation of risk reductions.
• Performs functions of the risk management program at the Site and provides feedback to Director and Manager.
  • Implements the loss control and loss prevention activities, is aware of the statistical trending of losses, the analysis and assists the Manager in responding to patterns in the data
  • Conducts routine unit/department rounds to assess risk, identify actual or potential liability exposures to patients, associates, visitors and physicians. Provides 24/7 Risk Management on call coverage for the site.
  • Assist in completing the department quarterly Risk report card.
  • Attends Site Safety Huddles, Risk Management Huddles or Monthly Support Center Risk Management meetings when assigned.
  • Provides suggestions in preparation of departmental goal, objectives and budget.
• Assists in developing educational programs on health care risk management, general and professional Liability, and related topics for health care practitioners including educational materials and publications.
  • Provides orientation to new associates and physicians regarding risk and liability, event reporting and related processes and policies.
  • Provides in-service training for associates in reporting of adverse events and on topics related to risk management and professional liability.
• Works with Patient Relations/Guest Services staff to identify patient complaints that are to be reported as event reports.
  • Refers patient/customer complaints with potential liability exposures to Manager and Claims Administration and maintains compliance to grievance resolution
  • Assists the Language Services program in reporting patient safety events and conducts investigations on potential liability exposures.
• Notifies the Manager and Advocate Legal Department on those issues that may include but are not limited to, guardianship requests, policy reviews, operational liability issues, interpretation of codes, statutes, laws or regulations, notice of governmental investigations or other issues requiring legal notification or opinion.

Education Required:

Bachelor's Degree, certification/certificate in legal field, RN or other clinical licensure in healthcare field preferred. Five years recent healthcare experience required, previous risk management, claims or insurance experience preferred. Knowledge of federal and Illinois law related to healthcare.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.