Reviews settled insurance claims to determine that payments and settlements have been made in accordance with company practices and procedures. Reports overpayments, underpayments, and other irregularities. Confers with legal counsel on claims requiring litigation.
This career is part of the Business Management and Administration cluster Business Finance and Accounting pathway.
A person in this career:
- Investigates, evaluates, and settles claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.
- Adjusts reserves or provides reserve recommendations to ensure that reserve activities are consistent with corporate policies.
- Resolves complex, severe exposure claims, using high service oriented file handling.
- Pays and processes claims within designated authority level.
- Examines claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
- Verifies and analyzes data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
- Enters claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
- Confers with legal counsel on claims requiring litigation.
- Contacts or interviews claimants, doctors, medical specialists, or employers to get additional information.
- Maintains claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.