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