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