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