Main Responsibilities and Required Skills for a Claims Representative
A Claims Representative is a professional who plays a crucial role in the insurance industry. They are responsible for handling and processing insurance claims on behalf of policyholders. Their primary goal is to ensure that claims are processed accurately, efficiently, and in compliance with the company's policies and procedures. In this blog post, we describe the primary responsibilities and the most in-demand hard and soft skills for Claims Representatives.
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Main Responsibilities of a Claims Representative
The following list describes the typical responsibilities of a Claims Representative:
Achieve
Achieve and maintain the appropriate service levels on the queue.
Address
Address and resolve customer complaints or escalations regarding claim handling or outcomes.
Address customers' service needs in a professional, positive, and timely manner.
Adhere to
Adhere to established timelines for claim processing, ensuring prompt resolution and payment.
Adjust
Adjust the claim from inception to completion in a proactive manner.
Administer
Administer subrogation of claims and negotiates settlements.
Analyze
Analyze claim data and statistics to identify patterns or trends that can inform process improvements or risk management strategies.
Analyze complex claim situations, policy terms, and legal requirements to make informed decisions.
Answer
Answer and manage calls for Insured, Brokers and Business Partners.
Answer incoming telephone or email inquiries from customers regarding the status of their claim.
Arrange
Arrange property or vehicle inspections, collaborating with field adjusters or external experts as necessary.
Ask
Ask the right questions to gain necessary information without doing so in a leading manner.
Assemble
Assemble additional information as required from outside sources.
Assess
Assess the extent of coverage and determine the amount payable for each claim.
Assist
Assist other employees to ensure proper project and program coverage and service.
Attend
Attend mediations and pre-trials when required.
Attend mediations, arbitrations, pre-trial conferences.
Attend mediations, court proceedings and other dispute resolution processes, as required.
Benefit
Benefit and eligibility information.
Build
Build and maintain positive relationships with policyholders, agents, and other stakeholders to promote customer satisfaction and loyalty.
Calculate
Calculate benefits payable under the policy and either make payments or decline payments on claims.
Check
Check internal records to help AR reconcile accounts.
Collaborate with
Collaborate with internal departments, such as underwriting or legal teams, to obtain necessary information or support during the claims process.
Collaborate with other departments as needed to verify or obtain missing information.
Collaborate with other teams within the Property department.
Collect
Collect detailed information about the claim and enter into the AS400 system.
Collect reports and statements to determine liability and coverage.
Communicate
Communicate claim action with claimant and client.
Communicate with attending physician, employer and injured worker.
Communicate with Commercial Lines brokers to build collaborative relationships.
Complete
Complete appropriate reports.
Complete internal training in adjusting medical only workers' compensation claims.
Complete PARs (payment authorization request) or CARs (claims analysis report) when applicable.
Complete thorough claim investigations.
Compose
Compose routine correspondence or documents, such as form letters.
Conduct
Conduct thorough investigations to determine the validity of insurance claims.
Confirm
Confirm coverage and applicable insurance policy or coverage document and statutory requirements.
Confirm whether claims are covered under a customer's policy.
Contact
Contact Plan Members and Service Providers for verifications within specified times.
Contribute to
Contribute to overall Casualty Claims strategy initiatives and implementation.
Contribute to overall Claims strategy initiatives and implementation.
Coordinate
Coordinate services with vendors, service providers and experts.
Determine
Determine claim approval and or denial up.
Educate
Educate policyholders and agents on policy coverage, claim procedures, and other relevant information.
Engage
Engage in negotiations with policyholders, claimants, and other involved parties to reach fair settlements.
Ensure
Ensure all cases are clearly documented and meet any or all legislative requirements.
Ensure all claims are promptly investigated.
Ensure claim files are properly documented and claims coding is correct.
Ensure compliance with regulatory requirements and internal policies throughout the claims handling process.
Ensure that all assigned claims are resolved timely, reserved accurately and handled fairly.
Ensure timely payment or denial of benefits in accordance with jurisdictional requirements.
Enter
Enter and locate work-related information using computers and / or other methods.
Enter and update claim information accurately in the company's claims management system.
Enter determination and relevant notes into PeopleSoft in accordance with guidelines.
Escalate
Escalate complex or high-value claims to supervisors or higher-level authority for further review and approval.
Establish
Establish an investigative plan.
Evaluate
Evaluate and adjust claims within limit of authority.
Evaluate and apply the insurance policy as it pertains to making payments and declination of claims.
Evaluate and resolve the more simple claims.
Evaluate claimant eligibility.
Evaluate claim facts and policy coverage.
Evaluate damages and losses to property, vehicles, or individuals to determine liability and compensation.
Evaluate relevant information from sources such as lawyers, medical providers and other experts.
Evaluate relevant information from sources such C&O, Engineers and other experts.
Evaluate settlement alternatives by reviewing regulatory compliance and fair claims practices.
Evaluate settlement criteria for payment of claims.
Facilitate
Facilitate the resolution of claim disputes or conflicts between parties involved.
Follow
Follow all company and safety and security policies and procedures.
Follow company and department policies and procedures.
Follow-up
Follow-up on previously reported claims.
Follow-up with customer either by letter, email or telephone call once the claim has been resolved.
Generate
Generate accurate and comprehensive reports on claim activities, outcomes, and trends for management review.
Handle
Handle between 150-300 claims on assignment.
Handle claim paperwork, forms, and documents promptly and accurately.
Handle field tasks on behalf of telephone adjusters.
Handle sensitive information with the utmost confidentiality and adhere to privacy regulations.
Handle single and multi-party, intermediate Auto Bodily Injury Liability Claims.
Identify
Identify and investigate potential cases of insurance fraud, reporting suspicious activities to the appropriate authorities.
Identify contractual and administrative adjustments.
Identify customer needs and works to meet those needs using appropriate customer service skills.
Identify potential for third party recovery, including subrogation.
Identify opportunities to streamline claim processes, reduce inefficiencies, and enhance customer experience.
Inform
Inform, give advice, and direct the callers.
Initiate
Initiate investigation by gathering facts and evidence with all interested parties.
Initiate salvage and subrogation procedures on assigned claims.
Inspect
Inspect property and auto damages and write repair estimates.
Interact with
Interact with all levels of staff.
Interact with policyholders, agents, and other parties involved to gather necessary information and provide updates on claim status.
Interpret
Interpret Auto policy coverage.
Interpret Commercial policy wordings, determine policy coverage and ensure appropriate reserving.
Interpret insurance policies, coverage terms, and exclusions to determine claim eligibility.
Interpret policy wordings, determine claim coverage and collaborate with Underwriting as required.
Interview
Interview insureds, claimants and witnesses.
Investigate
Investigate and coordinate insurance benefits for insurance claims across multiple service lines.
Investigate and settle routine towing & storage claims.
Investigate bodily injury claims to ensure a prompt and fair settlement.
Investigate Commercial losses to determine liability.
Investigate losses to determine liability, attending loss scene as required.
Investigate losses to determine liability in bodily injury claims as well as property damage losses.
Investigate potentially suspect claims, possibly with the aid of a field investigator assignment.
Keep
Keep customers properly informed of Company policies and procedures.
Keep up to date on Intact's insurance products, appraisal and investigation techniques, and services.
Maintain
Maintain accurate records based on company standards and policies within the claims system.
Maintain all files on computer diary for supervisor (or designee's) review.
Maintain and adjust reserves over the life of the claim to reflect changes in exposure.
Maintain confidentiality of proprietary information and protect company assets.
Maintain confidentiality of proprietary materials and information.
Maintain detailed file records by entering pertinent data into the appropriate systems.
Maintain detailed records of all claim activities, including conversations, correspondence, and decisions.
Maintain file litigation strategy and collaborate with legal partners.
Maintain professional client relationships.
Maintain targeted closure ratio.
Make
Make appropriate contacts to discuss a settlement.
Make decisions on best option.
Make independent decisions, think creatively, and be able to prioritize the key requirements needed.
Manage
Manage auto telephone claims through an inbound and outbound call centre environment.
Manage claims through the litigation process.
Manage repair assignments and provide updates on the claim.
Monitor
Monitor claim from inception to completion in a proactive manner.
Negotiate with
Negotiate with insureds, claimants, lawyers and insurers.
Obtain
Obtain / Maintain appropriate licensing or educational requirements.
Offer
Offer excellent customer service throughout the claims process, addressing inquiries and concerns professionally and empathetically.
Participate in
Participate at private mediation, court proceedings and other dispute resolution as required.
Participate in the management of loss and expense reserves.
Participate in training sessions or workshops to enhance knowledge and skills related to claims handling.
Perform
Perform special projects at management's request.
Prepare
Prepare and review written documents accurately and completely.
Prepare case overview(s) for department's Service Call Program.
Prepare reports for management as required.
Prepare reports of findings and secure settlements with insureds and claimants.
Present
Present large losses at executive committee meetings and recommend reserve increases as needed.
Process
Process claims payments within your authority level.
Process MMP / StarPlus claims based on Cigna and TMHP guidelines for payment or denial.
Process recoveries on subrogation / salvage files.
Protect
Protect the privacy and security of customers and co-workers.
Provide
Provide appropriate claims resolution documents.
Provide direction to assigned nurse case manager where applicable.
Provide exceptional customer service.
Provide exceptional customer service to our customers, brokers and preferred partners.
Provide guidance and advice to policyholders regarding claim processes, coverage options, and policy modifications.
Provide ongoing technical advice and guidance to junior claims representatives.
Provide ongoing technical advice and guidance to junior claims staff.
Provide ongoing technical advice and guidance to junior inside claims staff.
Provide prompt, courteous, accurate and fair claims service to all customers, internal and external.
Provide proper documentation and reporting of investigation and claims handling activities.
Provide superior and professional customer services.
Provide technical advice and guidance to junior staff.
Refer
Refer cases as appropriate to team lead.
Refer cases to the Investigative Services Unit or H&D Claims Operations Database.
Refer complex issues to supervisor.
Research
Research and analyze claims issues.
Research and resolve problems and questions or properly refers them to the correct department.
Research discrepancies and escalate questionable claims to Team Leader.
Research questions and problems.
Resolve
Resolve low to complex repair shop issues / questions.
Respond to
Respond to all customer follow-ups in a timely manner.
Respond to inquiries, may involve customer / client contact.
Review
Review and processes audit errors on a daily basis.
Review and understand eligibility of benefits.
Review auto claims and assist repair facilities with claims needs.
Review pending claims for Provider / Member / Authorization corrections within QNXT.
Review sales rep as well as store issued credits for accuracy and compliance.
Scrutinize
Scrutinize policy documents and related materials to ensure accuracy and adherence to guidelines.
Send out
Send out claim forms to new customers as needed.
Stay up to date with
Stay up to date with industry trends, regulations, and best practices related to claims handling.
Study
Study any documentation submitted.
Study documentation submitted.
Support
Support insureds on opening a claim in a proactive manner.
Support the organization's quality program(s).
Take
Take initiative to be proactive at resolving customer issues with a positive outcome.
Talk
Talk with and listen to other employees to effectively exchange information.
Transmit
Transmit information or documents using mail, scanner, or facsimile machine.
Update
Update active Spreadsheets.
Uphold
Uphold confidentiality regarding protected health information and adhere to HIPPA regulation.
Verify
Verify policyholders' coverage, policy limits, and deductibles to determine the scope of the claim.
Work
Work and communicates clearly and effectively with Supervisor and Team Leads.
Work with the customer and preferred vendors to determine the best way to resolve the claim.
Write
Write customer credits that comply with UNFI's credit policy.
Write scope and estimate of loss using property estimating software.
Most In-demand Hard Skills
The following list describes the most required technical skills of a Claims Representative:
Claims Management Systems (e.g., Guidewire, Duck Creek)
Insurance Principles and Policies: In-depth knowledge of insurance principles, policy terms, and coverage options.
Legal and Regulatory Compliance: Understanding of insurance laws, regulations, and compliance requirements.
Data Analysis: Proficiency in analyzing claim data, identifying patterns, and deriving insights to improve decision-making.
Documentation and Record-Keeping: Strong ability to maintain accurate and organized claim records and documentation.
Risk Assessment: Skill in assessing risks associated with different types of claims and determining appropriate courses of action.
Fraud Detection and Investigation: Familiarity with techniques and tools to detect and investigate potential cases of insurance fraud.
Negotiation and Settlement: Ability to negotiate effectively with claimants and other parties to reach fair and satisfactory settlements.
Damage Assessment: Knowledge of property, vehicle, or personal injury assessment methods to determine claim value.
Medical Terminology: Understanding of medical terminology and procedures related to injury claims.
Most In-demand Soft Skills
The following list describes the most required soft skills of a Claims Representative:
Communication: Excellent verbal and written communication skills to interact with policyholders, agents, and other stakeholders effectively.
Customer Service: Strong customer service orientation to provide empathetic and supportive assistance to claimants.
Problem-Solving: Ability to analyze complex situations, identify issues, and develop creative solutions to resolve claim challenges.
Attention to Detail: Meticulousness in reviewing claim documents, policies, and records to ensure accuracy and completeness.
Time Management: Effective prioritization and multitasking skills to manage multiple claims and meet deadlines.
Empathy: Capacity to understand and empathize with claimants during difficult or sensitive situations.
Conflict Resolution: Skill in resolving conflicts and managing difficult conversations with professionalism and diplomacy.
Adaptability: Flexibility and willingness to adapt to changing claim scenarios, policies, and industry trends.
Critical Thinking: Strong analytical and critical thinking abilities to evaluate information, assess risks, and make informed decisions.
Teamwork: Collaboration and teamwork skills to work effectively with colleagues, supervisors, and cross-functional teams to achieve common goals.
Conclusion
Being a Claims Representative requires a combination of technical expertise, analytical skills, and strong interpersonal abilities. By possessing the necessary hard and soft skills, Claims Representatives can effectively handle insurance claims, ensure customer satisfaction, and contribute to the success of their organizations.
