Claims Adjusters, Examiners, and Investigators

13-1031.00

Review settled claims to determine that payments and settlements are made in accordance with company practices and procedures. Confer with legal counsel on claims requiring litigation. May also settle insurance claims.

Occupation-Specific Information

Tasks

• Examine claims forms and other records to determine insurance coverage.
• Analyze information gathered by investigation and report findings and recommendations.
• Pay and process claims within designated authority level.
• 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.
• 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.
• Review police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.
• Investigate and assess damage to property and create or review property damage estimates.
• Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.
• Interview or correspond with claimants, witnesses, police, physicians, or other relevant parties to determine claim settlement, denial, or review.
• Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
• Resolve complex, severe exposure claims, using high service oriented file handling.
• Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
• Confer with legal counsel on claims requiring litigation.
• Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
• Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
• Refer questionable claims to investigator or claims adjuster for investigation or settlement.
• Collect evidence to support contested claims in court.
• Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
• Present cases and participate in their discussion at claim committee meetings.
• Report overpayments, underpayments, and other irregularities.
• Attend mediations or trials.
• Supervise claims adjusters to ensure that adjusters have followed proper methods.
• Conduct detailed bill reviews to implement sound litigation management and expense control.
• Communicate with reinsurance brokers to obtain information necessary for processing claims.
• Prepare reports to be submitted to company's data processing department.
• Examine titles to property to determine validity and act as company agent in transactions with property owners.
• Obtain credit information from banks and other credit services.
• Communicate with former associates to verify employment record or to obtain background information regarding persons or businesses applying for credit.
• Negotiate claim settlements or recommend litigation when settlement cannot be negotiated.

Technology Skills

• Access software - CCC EZNet electronic communications network; CSC Automated Work Distributor AWD
• Analytical or scientific software - Injury Sciences EDR InSight; Insurance claims fraud detection software; Magnify Predictive Targeting System
• Computer aided design CAD software - 4n6xprt Systems StiffCalcs; ARSoftware WinSMAC; CAD Zone Insurance; MapScenes Evidence Recorder; MapScenes Pro; PhotoModeler; Visual Statement Investigator Suite
• Data base reporting software - Corporate Systems ClaimsPro
• Data base user interface and query software - Claims processing administration and management software; Fair Isaac Claims Advisor; Microsoft Access 🔥; Tropics Claims Reserve Management; Xactware Xactimate
• Desktop publishing software - Microsoft Publisher
• Document management software - Agency Management Systems AMS 360; AutoClaims Direct DirectLink; Automatic Data Processing Autosource; Automatic Data Processing Claims Manager & Dispatch; BCCORP Burkitt W5; BCCORP W5 for Adjusters; Bramerhill ClaimsTech; Bridium Claims 3; Brightwork Alyce Claims Systems; Captiva InputAccel; Castek Insure3 Claims; CCC Pathways Image Management Solution; CCC TL2000 Solution; CGI INSideOUT; Clear Technology Tranzax; Covansys ClaimConnect; Datanex ClaimTrac; Document management system software; Hyland OnBase Enterprise Content Management; InSystems Calligo Document Management System
• Electronic mail software - Microsoft Outlook
• Enterprise resource planning ERP software - ADP software; CCC Pathways Appraisal Quality Solution
• Expert system software - Axonwave Fraud and Abuse Management System; Bill review software; CCC GuidePost Decision Support; CSC Fault Evaluator; Fair Isaac SmartAdvisor; First Notice Systems ClaimCapture; Hummingbird Legal Bill Review; IBM Fraud and Abuse Management System; ISO ClaimSearch; ISO NetMap for Claims; LexisNexis RiskWise; StrataCare StrataWare eReview
• Financial analysis software - Automatic Data Processing Estimating; CSC Colossus; Property damage, bodily injury, and liability estimation software; QwikQuote software; Simsol for Adjusters; Turtle Creek Software Goldenseal Architect
• Information retrieval or search software - CGI-AMS BureauLink Enterprise
• Interactive voice response software - Computerized voice stress analyzer CVSA software
• Internet browser software - Apple Safari; Mozilla Firefox
• Medical software - Healthcare common procedure coding system HCPCS; Medical condition coding software; Medical procedure coding software
• Office suite software - Business software applications; Microsoft Office software
• Presentation software - Microsoft PowerPoint
• Spreadsheet software - Microsoft Excel
• Video conferencing software - Zoom 🔥
• Word processing software - Microsoft Word 🔥

Occupational Requirements

Work Activities

• Getting Information - Observing, receiving, and otherwise obtaining information from all relevant sources.
• Monitoring Processes, Materials, or Surroundings - Monitoring and reviewing information from materials, events, or the environment, to detect or assess problems.
• Identifying Objects, Actions, and Events - Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
• Inspecting Equipment, Structures, or Materials - Inspecting equipment, structures, or materials to identify the cause of errors or other problems or defects.
• Estimating the Quantifiable Characteristics of Products, Events, or Information - Estimating sizes, distances, and quantities; or determining time, costs, resources, or materials needed to perform a work activity.
• Judging the Qualities of Objects, Services, or People - Assessing the value, importance, or quality of things or people.
• Processing Information - Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
• Evaluating Information to Determine Compliance with Standards - Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
• Analyzing Data or Information - Identifying the underlying principles, reasons, or facts of information by breaking down information or data into separate parts.
• Making Decisions and Solving Problems - Analyzing information and evaluating results to choose the best solution and solve problems.
• Thinking Creatively - Developing, designing, or creating new applications, ideas, relationships, systems, or products, including artistic contributions.
• Updating and Using Relevant Knowledge - Keeping up-to-date technically and applying new knowledge to your job.
• Developing Objectives and Strategies - Establishing long-range objectives and specifying the strategies and actions to achieve them.
• Scheduling Work and Activities - Scheduling events, programs, and activities, as well as the work of others.
• Organizing, Planning, and Prioritizing Work - Developing specific goals and plans to prioritize, organize, and accomplish your work.
• Performing General Physical Activities - Performing physical activities that require considerable use of your arms and legs and moving your whole body, such as climbing, lifting, balancing, walking, stooping, and handling materials.
• Handling and Moving Objects - Using hands and arms in handling, installing, positioning, and moving materials, and manipulating things.
• Controlling Machines and Processes - Using either control mechanisms or direct physical activity to operate machines or processes (not including computers or vehicles).
• Operating Vehicles, Mechanized Devices, or Equipment - Running, maneuvering, navigating, or driving vehicles or mechanized equipment, such as forklifts, passenger vehicles, aircraft, or watercraft.
• Working with Computers - Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
• Drafting, Laying Out, and Specifying Technical Devices, Parts, and Equipment - Providing documentation, detailed instructions, drawings, or specifications to tell others about how devices, parts, equipment, or structures are to be fabricated, constructed, assembled, modified, maintained, or used.
• Repairing and Maintaining Mechanical Equipment - Servicing, repairing, adjusting, and testing machines, devices, moving parts, and equipment that operate primarily on the basis of mechanical (not electronic) principles.
• Repairing and Maintaining Electronic Equipment - Servicing, repairing, calibrating, regulating, fine-tuning, or testing machines, devices, and equipment that operate primarily on the basis of electrical or electronic (not mechanical) principles.
• Documenting/Recording Information - Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
• Interpreting the Meaning of Information for Others - Translating or explaining what information means and how it can be used.
• Communicating with Supervisors, Peers, or Subordinates - Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
• Communicating with People Outside the Organization - Communicating with people outside the organization, representing the organization to customers, the public, government, and other external sources. This information can be exchanged in person, in writing, or by telephone or e-mail.
• Establishing and Maintaining Interpersonal Relationships - Developing constructive and cooperative working relationships with others, and maintaining them over time.
• Assisting and Caring for Others - Providing personal assistance, medical attention, emotional support, or other personal care to others such as coworkers, customers, or patients.
• Selling or Influencing Others - Convincing others to buy merchandise/goods or to otherwise change their minds or actions.
• Resolving Conflicts and Negotiating with Others - Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.
• Performing for or Working Directly with the Public - Performing for people or dealing directly with the public. This includes serving customers in restaurants and stores, and receiving clients or guests.
• Coordinating the Work and Activities of Others - Getting members of a group to work together to accomplish tasks.
• Developing and Building Teams - Encouraging and building mutual trust, respect, and cooperation among team members.
• Training and Teaching Others - Identifying the educational needs of others, developing formal educational or training programs or classes, and teaching or instructing others.
• Guiding, Directing, and Motivating Subordinates - Providing guidance and direction to subordinates, including setting performance standards and monitoring performance.
• Coaching and Developing Others - Identifying the developmental needs of others and coaching, mentoring, or otherwise helping others to improve their knowledge or skills.
• Providing Consultation and Advice to Others - Providing guidance and expert advice to management or other groups on technical, systems-, or process-related topics.
• Performing Administrative Activities - Performing day-to-day administrative tasks such as maintaining information files and processing paperwork.
• Staffing Organizational Units - Recruiting, interviewing, selecting, hiring, and promoting employees in an organization.
• Monitoring and Controlling Resources - Monitoring and controlling resources and overseeing the spending of money.

Detailed Work Activities

• Calculate data to inform organizational operations.
• Investigate legal issues.
• Prepare legal or investigatory documentation.
• Pay charges, fees, or taxes.
• Negotiate agreements to resolve disputes.
• Verify accuracy of records.
• Estimate costs of goods or services.
• Appraise property values.
• Interview witnesses, suspects, or claimants.
• Maintain data in information systems or databases.
• Apply information technology to solve business or other applied problems.
• Resolve customer complaints or problems.
• Implement financial decisions.
• Advise others on financial matters.
• Meet with individuals involved in legal processes to provide information and clarify issues.
• Prepare financial documents.
• Report information to managers or other personnel.
• Collect evidence for legal proceedings.
• Present business-related information to audiences.
• Supervise employees.
• Examine financial records.
• Confer with others about financial matters.
• Prepare operational reports.
• Gather financial records.
• Verify application data to determine program eligibility.
• Advise others on legal or regulatory compliance matters.