Claims Job Description

Claims Job Description

4.5
144 votes for Claims
Claims provides claims management oversight of all lines of insured claims (workers’ compensation, auto / general / products liability, aviation / marine liability, executive risk, employment practices liability, property / business interruption, etc.) across the organization amounting to over 10,000 reported claims per year with over $120M in total claim dollars.

Claims Duties & Responsibilities

To write an effective claims job description, begin by listing detailed duties, responsibilities and expectations. We have included claims job description templates that you can modify and use.

Sample responsibilities for this position include:

All Claims Representatives must maintain the highest level of confidentiality and comply with all HIPAA regulations and Business Associate Agreements with its clients
Reviews work in progress provides training or assistance in processing to insure quality standards are met
Handles personnel actions including interviewing, hiring, firing, performance reviews, salary recommendations, and coordinates training and development
In collaboration with Director and Vice President, establish overall department budget
Coordinate benefits with all available payers to appropriately maximize the client’s recovery while minimizing the patient’s personal responsibility
Review and process for payment all claims, in which adequate billing information has been obtained, to the appropriate insurance carrier within 24 hours of receipt of said information
Review status of litigated claims (if applicable) and confer with attorneys and third party carriers regarding case disposition
Converse with the insurer(s) and appeal when appropriate to guarantee that all available benefits are recovered and that claims are reimbursed at the appropriate/maximum level(s)
Professionally respond to customer inquiries and requests that may require extracting, synthesizing, and analyzing system data
Prepare account summaries, offers of compromise, pro ration of funds, and compile other relevant data

Claims Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Claims

List any licenses or certifications required by the position: CII, APICS, UW, ICD, CPT, B2, ASE, I.E.A, S.I.P, FEMA

Education for Claims

Typically a job would require a certain level of education.

Employers hiring for the claims job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and University Degree in Education, Business, Associates, Graduate, General Education, Law, Technical, Management, Finance, Healthcare

Skills for Claims

Desired skills for claims include:

Claim file process through presentation of actions and responses to client questions
Accepted industry standards and practices Computer experience with related claims and business software
Regulations
Accepted industry standards and practices
Offsets and deductions
Medical terminology
Disability duration
Medical management practices and Social Security and Medicare application procedure as applicable to line of business
Legal liability
Estimatics software

Desired experience for claims includes:

Remain current with all local, state and federal statutes and act within the limits of the law
Understand all specific billing requirements for each applicable state and payer
Establish and maintain constructive working relationships with insurance carriers, clients, external business contacts and staff
Knowledge of claims handling, processes and procedures
Obtains relevant technical information to support decision making or selling risk improvement programs
Data analysis and benchmarking

Claims Examples

1

Claims Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of claims. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims
  • Providing status on open deductions, reported claims, account issues, and trending
  • Works with claims leaders to identify skill or knowledge gaps, conduct needs assessments to determine training solution, provide consultation to business on training matters and identify key measures of success
  • Deliver training solutions to employees/leaders or prepare subject matter experts for delivery of training and determine training solutions to fill those gaps
  • Provide project management oversight on training solutions that covers all phases from design/development to implementation/delivery and measurement to assure a successful result
  • Develop strong partnerships with subject matter experts across business units HR to create an effective network of resources to assist with training needs
  • Handle some complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members
  • Research plan information and identify where there may be conflicting information
  • Assist members with setting up payment arrangements
  • Utilize all resources available to analyze and resolve billing issues
  • Plan documents including SPD’s, benefit summaries and open enrollment materials, interpretation of benefits
Qualifications for claims
  • Ability to work independently within reserve authority and provide recommendations for claims over authority to present to Claims Manager
  • Experienced in dealing with claims handling aspects of a file, pre-litigation and during litigation previous experience of defending insurance claims
  • 1+ year of Claims and/or Billing Claims experience
  • Ability to maintain and display a positive attitude at all times
  • Understanding of medical, dental, vision, behavioral health
  • Assist with billing and claims adjudication process
2

Claims Job Description

Job Description Example
Our company is growing rapidly and is hiring for a claims. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for claims
  • Prepare monthly/quarterly claim analytics reports for management
  • Help analyze key performance indicators for the claims organization
  • Work with large data for ad hoc reporting and trend analysis
  • Assist with the forecasting and claims strategy
  • Help with Fraud, subrogation, medical management and legal analytics
  • Manage various claim related databases
  • Analyze and validate reinsurance files and corresponding premium payments
  • Provide assistance and ensure transparency in the communication to key internal and external clients , IT, business development, actuarial
  • Assisting multiple lines of business with operations duties
  • Analysis & resolution of both routine and complicated work requests
Qualifications for claims
  • Time spent in pursuit of a Bachelor’s degree
  • Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred
  • Bachelor’s degree in economics/finance/mathematics or Computer Science (preferred)
  • Prior experience as an analyst and/or knowledge of data mining is preferred
  • Prior insurance or reinsurance experience is preferred but not mandatory
  • Advanced knowledge Microsoft Office
3

Claims Job Description

Job Description Example
Our innovative and growing company is looking for a claims. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims
  • Manages team
  • Review complex claims and/or situations and make informed decisions that may require judgment by providing direction on life, disability, excess risk, or critical illness claims
  • Refer cases to legal and/or may represent company in legal matters surrounding claims decisions
  • Participate and/or facilitate various department and/or company project and special initiatives
  • Manages and oversees the personnel actions for the claims processing team, which includes but is not limited to hiring and scheduling employees
  • Manages and oversees activities of the claims processing team, which includes defining and/or enforcing policies setting standards for the timely receipt, review, research and resolution of claims issues
  • Performs audits or coordinates audits of department operations and performance in meeting Company standards and customer service expectations
  • Provides reports of the team’s performance and productivity audit findings to the Director of Claims or other Operations leadership in a timely manner
  • Organizes and coordinates employee meetings, activities or programs to support open communication, motivate staff and foster employee morale
  • Acts as a critical point of escalation and works to resolve denied or pending claims as expeditiously as possible
Qualifications for claims
  • Advanced working knowledge of Workers’ Compensation statutory requirements, with strong experience preferred with California Workers’ Compensation claims management
  • Ability to work with various customers
  • Proficiency in office products such as Word, Excel and Outlook required
  • Strong customer orientation and excellent communication skills
  • Intermediate expertise in VBA, SQL, Access and Excel
  • College degree in Business, Math, English, Legal or other related subject (and/or equivalent work experience)
4

Claims Job Description

Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of claims. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims
  • Individual will learn, understand and be able to utilize state dig laws and statutes , 811 excavator requirements, NESC standards, CGA guidelines
  • Claims advocacy for our clients
  • Actively follow team procedures
  • Understand where KPI levels are consistently met or exceeded
  • Manages all workers' compensation claims processes including setting reserves, action plans, depositions, settlement negotiations/mediations and litigation
  • Responsible for administering the Workers' Compensation program in monopolistic states and the Canadian provinces
  • Manages the corporate reporting requirements from OSHA
  • Coordinating and managing communication with internal and external stakeholders (e.g., underwriting, brokers, reinsurers, external vendors, ) to ensure the highest level of customer service
  • Establish facts during the investigation of loss or incident
  • Identify, analyze and confirm coverage
Qualifications for claims
  • Advanced problem solving, multi-tasking and organizational skills
  • Ability to read legal terms and conditions and understand their meaning and how it applies to work processes
  • PC skills including (but not limited to) advanced Word, Excel, Access, and Internet
  • Legal documentation (credit agreements, amendments)
  • Review and consume information, formulate a recommendation based on language
  • Ability to grasp complex scenarios
5

Claims Job Description

Job Description Example
Our growing company is hiring for a claims. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for claims
  • Develop a strong relationship with the Reinsurance Carriers, Reinsurance Brokers, Actuaries, Captive Manager and other external parties
  • Develop trending analysis/reports on losses and incident
  • Attend Depositions, Mediations and Trial when required
  • Travel throughout Indiana and Illinois where facilities are located
  • Facilitate the management of open claims with defense counsel
  • Review claim files for appropriate billings and actions by defense counsel
  • Document all communication between internal and external parties to maintain a completed claim file
  • Work with associates at each community to ensure a prompt response and resolution of each incident
  • Investigate claims by collecting pictures, statements, contracts, leases, to provide a complete record to claims adjuster for review and resolution
  • Serve as system owner and relationship manager for the risk management information system
Qualifications for claims
  • A high level of analytical skills is necessary
  • Previous coaching experience is required
  • In-depth knowledge of claims files handling, investigation and settlement processes and procedures
  • Manages and develops a team focused on meeting or exceeding established performance targets
  • 5 years claims management required, ideally with a health maintenance organization or health insurance carrier
  • Ensures execution of claim handling strategies

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