Will “Case Manager” 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 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 Director
- Claims Consultant
- Claims Auditor
- Claims Account Specialist
- Claims Account Manager
- Claim Auditor
- Check Examiner
- Casualty Claims Supervisor
Tasks for “Case Manager”
- Supervise claims adjusters to ensure that adjusters have followed proper methods.
- Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
- Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
- Pay and process claims within designated authority level.
- Resolve complex, severe exposure claims, using high service oriented file handling.
- Communicate with reinsurance brokers to obtain information necessary for processing claims.
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
- Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
- Confer with legal counsel on claims requiring litigation.
- 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.
- Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- 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.
- Conduct detailed bill reviews to implement sound litigation management and expense control.
- Present cases and participate in their discussion at claim committee meetings.
- Report overpayments, underpayments, and other irregularities.
Related Technology & Tools
- Scanners
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- Personal computers
- Notebook computers
- Tablet computers
- Personal digital assistants PDA
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- AutoClaims Direct DirectLink
- Agency Management Systems AMS 360
- CCC EZNet electronic communications network
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- CGI INSideOUT
- Datanex ClaimTrac
- CCC TL2000 Solution
- Covansys ClaimConnect
- ISO ClaimSearch
- CCC GuidePost Decision Support
- Claims processing administration and management software
- Medical condition coding software
- Microsoft Office
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- IBM Fraud and Abuse Management System
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- BCCORP W5 for Adjusters
- Fair Isaac Claims Advisor
- Bridium Claims 3
- Axonwave Fraud and Abuse Management System
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- Automatic Data Processing Autosource
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- Computerized voice stress analyzer CVSA software
- InSystems Calligo Document Management System
- CSC Automated Work Distributor AWD
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- Captiva InputAccel
- Microsoft Excel
- CSC Fault Evaluator
- Healthcare common procedure coding system HCPCS
- Fair Isaac SmartAdvisor
- Microsoft PowerPoint
- Brightwork Alyce Claims Systems
- CCC Pathways Appraisal Quality Solution
- Bill review software
- ISO NetMap for Claims
- LexisNexis RiskWise
- Microsoft Word
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- StrataCare StrataWare eReview