• To analyze mid- and higher-level general liability claims to determine benefits due. • To ensure ongoing adjudication of claims within company standards and industry best practices. • To identify subrogation of claims and negotiate settlements. • Manages mid-level general liability claims by gathering information to determine liability exposure. • Assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level. • Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract. • Communicates claim action with claimant and client. • Ensures claim files are properly documented and claims coding is correct. • May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.

• coordinate with clients to gather all relevant information necessary to respond to unemployment claims and wage audits • file appeals to determinations with state agencies to request hearings be scheduled • prepare and submit comprehensive responses to the state request for information that provides the best chance of a successful outcome • assess and respond to requests for additional information from state agencies • develop partnerships with client contacts and use those relationships to coach on what additional steps or processes to have more successful outcomes • analyze unfavorable determinations and advise clients on likelihood of success on appeal • prioritize tasks and make sure to complete any pending items promptly

• Codes and enters imaged claims and triages adjustments, submitted by members, providers and vendors. • Reviews and corrects on-line edit errors by interpreting generated warning messages. • Uses appropriate systems to research and accurately process claims. • Researches appropriate reference documents and imaged claims to make coding and payment decisions. • Reviews and processes claims that are in a pended status in accordance with processing procedures, policies and current contract specifications regarding coverage, contract limitations, and exceptions. • May identify and report possible system or Image problems to CPR or Supervisor so that corrective action may be taken. • All other duties and assignments as directed.

• Evaluate appropriateness of beneficiaries' admission to nursing facilities • Verify documentation of medical necessity for prior approval requests • Meet performance expectations by completing at least 40 prior approval reviews daily • Achieve quality assurance reviews with greater than 95% accuracy • Complete timely reviews within 24 hours