Legal Claims Specialist

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Legal Claims Specialist
Duties: Performs work that requires knowledge of legal concepts and identifies legal issues related to assigned matters. Resolves routine and moderately complex matters in areas of responsibility with minimal supervision. Strategizes and consults with appropriate members of the Claims team (supervisor, manager and/or attorneys), in resolving claims. Prepares a plan of investigation and communication upon notification of a claim. Participates in tactical planning and assessment with the supervisor and/or attorney in negotiations with customers and patients. Recommends and negotiates settlement of claims, as directed. Manages moderately complex department projects using effective delivery strategies. Reviews, evaluates, and develops reports to include data summaries across multiple databases, systems, and software. Possesses solid knowledge of **MEMBERS ONLY**SIGN UP NOW***.’s businesses supported and knowledge of the broader business impact. Assesses the alleged complaint and performs investigations on claim allegations with all relevant stakeholders, including collection and evaluation of medical records, as appropriate. Receives and responds appropriately to routine and non-routine requests using good judgment and effective communication skills. Evaluates requests for compensation from patients. Evaluates documentation provided and conducts follow-up research with hospitals, insurance companies, and Medicare, as necessary. Responsible for initial triage and assignment of routine claims to junior specialists. Supports more senior claims specialists, supervisors or attorneys on more complex claims. Supports and complies with U.S. Food and Drug Administration (FDA) regulations, other regulatory requirements, Company policies, operating procedures, processes, and task assignments. Responsible for auditing department’s compliance with internal policies. Responsible for accurate filing and reporting of settlements as required by Medicare Secondary Payer (MSP) reporting requirements included in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007. Responsible for generating reports and reconciling data discrepancies within existing databases. Responsible for maintaining templates and prepares updates to templates. Maintains positive and cooperative communications and collaboration with all levels of employees, customers, contractors, and claimants. Performs other related duties and responsibilities, as assigned.

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