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