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.
- 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.
- Supervise claims adjusters to ensure that adjusters have followed proper methods.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
- 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.
- Present cases and participate in their discussion at claim committee meetings.
- Confer with legal counsel on claims requiring litigation.
- Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
- Pay and process claims within designated authority level.
- Report overpayments, underpayments, and other irregularities.
- Resolve complex, severe exposure claims, using high service oriented file handling.
- Conduct detailed bill reviews to implement sound litigation management and expense control.
- Communicate with reinsurance brokers to obtain information necessary for processing claims.
Related Technology & Tools
- Notebook computers
- Tablet computers
- Personal digital assistants PDA
- Desktop computers
- Scanners
- Personal computers
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- IBM Fraud and Abuse Management System
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- Datanex ClaimTrac
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- Clear Technology Tranzax
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- CCC Pathways Appraisal Quality Solution
- Healthcare common procedure coding system HCPCS
- Automatic Data Processing Autosource
- Insurance claims fraud detection software
- Tropics Claims Reserve Management
- CSC Fault Evaluator
- CGI INSideOUT
- Medical procedure coding software
- LexisNexis RiskWise
- Brightwork Alyce Claims Systems
- Microsoft Excel