Will “Claim Auditor” be Replaced By Robots? 🤔
Unknown Chance of Automation
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Job Description
Review settled insurance claims to determine that payments and settlements have been made in accordance with company practices and procedures. Report overpayments, underpayments, and other irregularities. Confer with legal counsel on claims requiring litigation.
Job Details
- The SOC (Standard Occupational Classification) code is 13-1031.01
☝️ Information based on the reference occupation “Claims Examiners, Property and Casualty Insurance”.
Also Known As…
- Claims Examiners, Property and Casualty Insurance
- Home Office Claim Specialist
- Customer Care Specialist
- Corporate Claims Examiner
- Claims Supervisor
- Claims Specialist
- Claims Representative
- Claims Manager
- Claims Examiner
- Claims Analyst
- Claims Adjuster
- Workers Compensation Examiner
- Workers Compensation Claims Examiner
- Worker's Compensation Claims Examiner
- Reinsurance Claim Analyst
- Property Damage Claims Adjustor
- Litigation Examiner
- Liability Claims Representative
- Liability Claims Manager
- Liability Claims Examiner
- Insurance Examiner
- Insurance Auditor
- Home Office Claims Examiner
- Executive Relations Specialist
- Claims Vice President
- Claims Director
- Claims Consultant
- Claims Auditor
- Claims Account Specialist
- Claims Account Manager
- Check Examiner
- Casualty Claims Supervisor
- Case Manager
Tasks for “Claim Auditor”
- Conduct detailed bill reviews to implement sound litigation management and expense control.
- Report overpayments, underpayments, and other irregularities.
- Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
- Resolve complex, severe exposure claims, using high service oriented file handling.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
- Pay and process claims within designated authority level.
- Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
- Present cases and participate in their discussion at claim committee meetings.
- Confer with legal counsel on claims requiring litigation.
- Investigate, evaluate, and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.
- Communicate with reinsurance brokers to obtain information necessary for processing claims.
- Prepare reports to be submitted to company's data processing department.
- Supervise claims adjusters to ensure that adjusters have followed proper methods.
- Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
Related Technology & Tools
- Desktop computers
- Scanners
- Personal computers
- Notebook computers
- Personal digital assistants PDA
- Tablet computers
- First Notice Systems ClaimCapture
- Microsoft Office
- Clear Technology Tranzax
- Automatic Data Processing Claims Manager & Dispatch
- CCC EZNet electronic communications network
- Fair Isaac SmartAdvisor
- Medical procedure coding software
- Hummingbird Legal Bill Review
- LexisNexis RiskWise
- AutoClaims Direct DirectLink
- Automatic Data Processing Autosource
- Medical condition coding software
- CCC TL2000 Solution
- IBM Fraud and Abuse Management System
- Computerized voice stress analyzer CVSA software
- CCC Pathways Image Management Solution
- CCC GuidePost Decision Support
- ISO NetMap for Claims
- Tropics Claims Reserve Management
- Microsoft PowerPoint
- CSC Fault Evaluator
- CCC Pathways Appraisal Quality Solution
- Fair Isaac Claims Advisor
- StrataCare StrataWare eReview
- Claims processing administration and management software
- Bridium Claims 3
- Bramerhill ClaimsTech
- ISO ClaimSearch
- Captiva InputAccel
- BCCORP W5 for Adjusters
- Insurance claims fraud detection software
- InSystems Calligo Document Management System
- Castek Insure3 Claims
- Bill review software
- Axonwave Fraud and Abuse Management System
- Microsoft Excel
- Datanex ClaimTrac
- Magnify Predictive Targeting System
- Agency Management Systems AMS 360
- CSC Automated Work Distributor AWD
- CGI INSideOUT
- Document management system software
- Covansys ClaimConnect
- Corporate Systems ClaimsPro
- Microsoft Word
- Healthcare common procedure coding system HCPCS
- Hyland OnBase Enterprise Content Management
- Brightwork Alyce Claims Systems