Claims Rep Job Description

Claims Rep Job Description

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Claims rep provides timely and effective claim service; handle administration of Federal Medical Leave Act (FMLA) and Leave of Absence (LOA) disability claims arising under disability insurance or leave of absence policies.

Claims Rep Duties & Responsibilities

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

Sample responsibilities for this position include:

Answers telephone calls from members and providers identifying those within the parameters established as being handled in the Member Service Department including referrals, certifying outpatient services, quoting benefits, triaging crisis and urgent calls to clinical care managers
Various forms of data entry including updating of the case management system to reflect the receipt of documents, statuses, and outcomes
Manage bulk letter creation processes
Perform a number of interest & fee calculations used to execute quality control
Review customer credits for accuracy, update credit outcomes as needed
Maintain claim information, accompanying data, and statues in claims case management system
Perform a number of account level money movement functions
Meet performance expectations related to productivity, effectiveness and customer experience
Also review estimates to determine if reported damages are consistent with accident facts
Conduct claim handling in compliance with appropriate State and Federal regulations

Claims Rep Qualifications

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

Licensing or Certifications for Claims Rep

List any licenses or certifications required by the position: ASE

Education for Claims Rep

Typically a job would require a certain level of education.

Employers hiring for the claims rep job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Education, Business, Engineering, Graduate, Associates, Management, General Education, Health Care, Accounting, Business/Administration

Skills for Claims Rep

Desired skills for claims rep include:

Products
Services
Claims and products
Re-consideration process
Various operations of the organization
Producers and industry trends
Insurance policies and coverage
Claim payments procedures and familiarity with medical terminology
Insurance policies and medical terminology helpful
Fault assessment and subrogation principles

Desired experience for claims rep includes:

Documenting all relevant facts and information in tracking systems in a timely manner to reflect appropriate claim status information is also needed
Communicates with customers regarding service request or problems
Functions w/in a team based environment, and actively participates in achieving team goals
Communicates with customers and agents regarding service request or problems
Good understanding of the application of benefit contracts, pricing, processing, policies, procedures, gov't regs, coordination of benefits, & healthcare terminology
Completion and submission of claims, when required

Claims Rep Examples

1

Claims Rep Job Description

Job Description Example
Our company is looking for a claims rep. 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 rep
  • Partner with foreclosure attorneys to expedite resolution of title liens and to prepare loan payoff/reinstatement figures
  • May have responsibility over more complex aspects of the loan pipeline
  • Obtains information about accidents and injuries from customers and claimants through telephone and written reports
  • Prepares and bundles incoming provider disputes for daily submission to contracted vendor for electronic imaging
  • Answer incoming calls from a queue
  • Reviews and researches policy contract, regulation and cause of injury to make coverage decisions
  • Recognizes the potential exposure of a claim and adjust reserves accordingly
  • Identifies, reviews and researches wage loss expenses and documentation for payment consideration
  • Conducts research to understand correlations between medical records and motor vehicle accidents, injuries or medical conditions
  • 2+ year(s) of experience in fast-paced call center atmosphere as a Call Center Representative
Qualifications for claims rep
  • Claims knowledge is helpful
  • Communicates effectively in a clear and concise manner (written & verbal)
  • Experience w/ de-escalating customer challenges
  • Excellent customer service skills / problem solving skills
  • Strong PC skills – ability to work/toggle into multiple systems
  • Ability to multi-task without impacting the quality of work
2

Claims Rep Job Description

Job Description Example
Our growing company is hiring for a claims rep. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for claims rep
  • First point-of-contact for members regarding their healthcare benefits and plans
  • 60+ calls daily inbound and outbound
  • Handle customer issues, retention of customers, and assisting with billing
  • 100% accuracy on leads, notes, and appointment creation
  • Fully proficient in all key areas
  • May participate in claims workflow projects
  • Responds to telephone and written inquiries and initiates steps to assist callers regarding issues relating to the content or interpretation of benefits, policies and procedures, provider contracts, and adjudication of claims
  • Adjusts voids and reopens claims on-line within guidelines to ensure proper adjudication
  • May have customer/client contact
  • May assist with training of staff
Qualifications for claims rep
  • Quickly and efficiently interprets requests, recognizes and investigates problems
  • Superior understanding of customer needs and a passion for assessing and providing solutions to address those needs
  • Must NOT be on any form of written counseling
  • Act as a role model to peers
  • 1 - 2 years related experience and/or training with an understanding of health plans, health plan eligibility and health care benefits, or equivalent combination of education and experience
  • Intermediate knowledge of healthcare industry and processes
3

Claims Rep Job Description

Job Description Example
Our growing company is searching for experienced candidates for the position of claims rep. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims rep
  • Produces a weekly claims recap that contains updates, changes, issues on claims for Member Services
  • Provides qualified data to the Business Operations Compliance & Regulatory Manager for incorporation into training programs and policies and procedures
  • Document all inquiries and complaints, including their resolution, appropriately in Service/CareConnect
  • Communicate the correct procedure for submitting claims so that the claim can be processed
  • Assist with monitor fax machine/printers and our new loss email address throughout the day for new assignments
  • Review of adjusters’ report submissions, including both technical and non-technical issues
  • This position reports to
  • Additionally, you will be required to assess the loss and establish appropriate reserves for these files
  • The field claim representatives will serve as the first responders and leaders in the field during catastrophe events
  • Creates reports on credentialing productivity, appeals and provider performance
Qualifications for claims rep
  • General knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms, and CPT Coding
  • Intermediate skill levels in Microsoft Word, Excel and Access
  • Fluency in French & English is a strong asset
  • Proven ability to communicate effectively, both verbally and in writing, and interact successfully with claimants, external suppliers, and third parties
  • Familiar with MS Office/Windows
  • Ability to handle emotionally charged situations
4

Claims Rep Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of claims rep. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claims rep
  • Answers incoming calls and resolves issues
  • Verifies eligibility and benefit questions
  • Reviews more complex accounts, files appropriate claims, and provides follow-up on claims
  • Contacts patients and insurance companies to identify barriers in getting more complex claims paid
  • Routes more complex accounts back to appropriate parties after self-pay balances are determined
  • Provides research on more complex bill disputes, handles adjustments and follows up on outstanding claims
  • You will be required to negotiate with insureds, claimants, public adjusters, attorneys and other professionals
  • This would include both day to day claim files catastrophe claim files that would cause a significant increase in claim volume during events
  • This will include responding and handling of catastrophe losses during events
  • Overall claim file and desk management that will include document gathering, written and phone inter-actions, estimate preparation, statements
Qualifications for claims rep
  • Possess a professional telephone manner
  • Experience in the Insurance Industry is an asset
  • Able to interpret the standard automobile policy and residential policy wordings an asset
  • Must have minimum 2 years of Call Center - Customer Service experience
  • Must have Claims experience & overview of CA sick pay
  • Must type 40 words/minute minimum
5

Claims Rep Job Description

Job Description Example
Our innovative and growing company is looking for a claims rep. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims rep
  • Provide training and support to the field claims adjusters to include estimate and file peer reviews
  • Handling of larger, more complex field property losses (valued over $100,000)
  • Review, investigate, analyze and adjust large and complex claims
  • You will be required to negotiate with insureds, claimants, public adjusters, attorneys or other professionals
  • The large loss representatives will serve as the first responders and leaders in the field during catastrophe events
  • As a large loss claim representative, you will ensure your technical skills are at a level that will permit you to serve as a subject matter expert for your line of business
  • This will include the development of training, help-guides, that will assist in the training of less experienced/new claim representatives
  • Additionally, you will participate in special projects and activities that will continue to drive the best in class behavior for the line of business
  • Expectations will exist that within this role, you will perform other duties as assigned
  • Maintains daily automated Acknowledgement and Resolution letter Microsoft mail merges
Qualifications for claims rep
  • Proficient with MS Office Suite (especially MS Outlook)
  • Three years of experience in claims field investigations
  • Must be able to represent the Company in Small Claims Court
  • Bachelor's Degree in Business or a related or an equivalent combination of education, training, and experience
  • Demonstrated experience investigating, evaluating, negotiating, and resolving personal injury and property damage claims including electrical and fire incidents
  • Demonstrated experience writing reports or memorandums such as property damage, business loss, accident, incident, investigation, collision, bodily injury, and fire, , using proper grammar, spelling, and punctuation

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