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”
- Present cases and participate in their discussion at claim committee meetings.
- Supervise claims adjusters to ensure that adjusters have followed proper methods.
- Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
- Resolve complex, severe exposure claims, using high service oriented file handling.
- 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.
- Pay and process claims within designated authority level.
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
- Conduct detailed bill reviews to implement sound litigation management and expense control.
- Report overpayments, underpayments, and other irregularities.
- Communicate with reinsurance brokers to obtain information necessary for processing claims.
- Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
- Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- 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.
- Prepare reports to be submitted to company's data processing department.
Related Technology & Tools
- Desktop computers
- Notebook computers
- Personal computers
- Scanners
- Tablet computers
- Personal digital assistants PDA
- Medical procedure coding software
- InSystems Calligo Document Management System
- Axonwave Fraud and Abuse Management System
- CSC Fault Evaluator
- Castek Insure3 Claims
- CCC GuidePost Decision Support
- Hyland OnBase Enterprise Content Management
- Bramerhill ClaimsTech
- Medical condition coding software
- Document management system software
- CCC Pathways Appraisal Quality Solution
- Captiva InputAccel
- CCC EZNet electronic communications network
- Clear Technology Tranzax
- Hummingbird Legal Bill Review
- Magnify Predictive Targeting System
- Datanex ClaimTrac
- Claims processing administration and management software
- Automatic Data Processing Autosource
- Covansys ClaimConnect
- Microsoft Office
- CCC TL2000 Solution
- Tropics Claims Reserve Management
- AutoClaims Direct DirectLink
- Brightwork Alyce Claims Systems
- IBM Fraud and Abuse Management System
- BCCORP W5 for Adjusters
- Bill review software
- ISO ClaimSearch
- Agency Management Systems AMS 360
- Fair Isaac Claims Advisor
- Microsoft PowerPoint
- Corporate Systems ClaimsPro
- Fair Isaac SmartAdvisor
- First Notice Systems ClaimCapture
- ISO NetMap for Claims
- StrataCare StrataWare eReview
- LexisNexis RiskWise
- Computerized voice stress analyzer CVSA software
- Microsoft Word
- Bridium Claims 3
- Healthcare common procedure coding system HCPCS
- Insurance claims fraud detection software
- CCC Pathways Image Management Solution
- CGI INSideOUT
- Microsoft Excel
- CSC Automated Work Distributor AWD
- Automatic Data Processing Claims Manager & Dispatch