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