• Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards • Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards • Ensure claim timeliness processing standards are being met • Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements • Assist internal and external partners with questions related to claims decisions or claims statuses • Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level

• Analyzes and processes complex or technically difficult general liability and litigated claims by investigating and gathering information to determine the exposure on the claim. • Manages claims through well-developed action plans to an appropriate and timely resolution. • Assesses liability and resolves claims within evaluation. • Negotiates settlement of claims within designated authority. • Calculates and assigns timely and appropriate reserves to claims.

• Analyzes and processes complex or technically difficult medical malpractice claims by investigating and gathering information to determine the exposure on the claim; • manages claims through well-developed action plans to an appropriate and timely resolution. • Conducts or assigns full investigation and provides report of investigation pertaining to new events, claims and legal actions. • Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout claim life. • Recommends settlement strategies; brings structured settlement proposals as necessary to maximize settlement. • Coordinates legal defense by assigning attorney, coordinating support for investigation, and reviewing attorney invoices; monitors counsel for compliance with client guidelines. • Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall claim cost for our clients. • Identifies and investigates for possible fraud, subrogation, contribution, recovery, and case management opportunities to reduce total claim cost. • Represents Company in depositions, mediations, and trial monitoring as needed. • Communicates claim activity and processing with the client; maintains professional client relationships. • Ensures claim files are properly documented and claims coding is correct. • Refers cases as appropriate to supervisor and management. • Performs other duties as assigned. • Supports the organization's quality program(s).

• Examine claim records and forms to investigate and resolve first level disputes, including completion of acknowledgement and determination letters • Review and process second level claims, such as adjustments and corrected claims • Work closely with leadership on identified trends related to improper processing and claim-related concerns or discrepancies that result in a dispute • Assist the team in carrying out departmental responsibilities and collaborate with others to support short- and long-term goals and priorities • Establish and maintain effective working relationships with team and collaboration with interdepartmental staff and leadership • Work closely with leadership on identified trends related to improper processing and claim related concerns or discrepancies that result in a dispute