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