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.
- 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.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- 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.
- 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.
- 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.
- Conduct detailed bill reviews to implement sound litigation management and expense control.
- Supervise claims adjusters to ensure that adjusters have followed proper methods.
- Report overpayments, underpayments, and other irregularities.
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
Related Technology & Tools
- Desktop computers
- Personal digital assistants PDA
- Personal computers
- Scanners
- Notebook computers
- Tablet computers
- Microsoft PowerPoint
- Microsoft Office
- First Notice Systems ClaimCapture
- Hummingbird Legal Bill Review
- Healthcare common procedure coding system HCPCS
- Magnify Predictive Targeting System
- Bill review software
- Fair Isaac Claims Advisor
- Medical procedure coding software
- Medical condition coding software
- Automatic Data Processing Autosource
- Claims processing administration and management software
- Bridium Claims 3
- Corporate Systems ClaimsPro
- Datanex ClaimTrac
- Microsoft Excel
- Castek Insure3 Claims
- Insurance claims fraud detection software
- CCC EZNet electronic communications network
- StrataCare StrataWare eReview
- Agency Management Systems AMS 360
- AutoClaims Direct DirectLink
- CGI INSideOUT
- Bramerhill ClaimsTech
- InSystems Calligo Document Management System
- Tropics Claims Reserve Management
- Covansys ClaimConnect
- BCCORP W5 for Adjusters
- ISO NetMap for Claims
- LexisNexis RiskWise
- Hyland OnBase Enterprise Content Management
- Clear Technology Tranzax
- ISO ClaimSearch
- CSC Automated Work Distributor AWD
- CCC TL2000 Solution
- Microsoft Word
- IBM Fraud and Abuse Management System
- CCC Pathways Image Management Solution
- Axonwave Fraud and Abuse Management System
- Brightwork Alyce Claims Systems
- CCC GuidePost Decision Support
- Document management system software
- Captiva InputAccel
- Fair Isaac SmartAdvisor
- CSC Fault Evaluator
- CCC Pathways Appraisal Quality Solution
- Computerized voice stress analyzer CVSA software
- Automatic Data Processing Claims Manager & Dispatch