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