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