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