Job Role Description

Medical > Claims Manager

Salary National Average

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48950.0000 77590.0000 90760.0000

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Short Description:

A Claims Manager oversees the processing and management of insurance claims within an organization, ensuring accurate, efficient, and fair handling of claims. Their responsibilities include supervising claims adjusters, reviewing complex cases, resolving disputes, and ensuring compliance with regulatory and company policies. Claims Managers also analyze claims data to identify trends and implement strategies to improve efficiency and reduce risks. Strong leadership skills, attention to detail, and a deep understanding of insurance practices are essential for success in this role, as Claims Managers play a crucial part in maintaining the integrity and financial health of the claims process.

Duties / Responsibilities:

  • 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.
  • Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
  • Resolve complex, severe exposure claims, using high service oriented file handling.
  • Pay and process claims within designated authority level.
  • Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
  • 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.
  • Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
  • Confer with legal counsel on claims requiring litigation.
  • Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
  • Maintain claim files such as records of settled claims and an inventory of claims requiring detailed analysis.

Skills / Requirements / Qualifications

  • Reading Comprehension: Understanding written sentences and paragraphs in work related documents.
  • Writing: Communicating effectively in writing as appropriate for the needs of the audience.
  • Active Listening: Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
  • Critical Thinking: Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
  • Speaking: Talking to others to convey information effectively.
  • Negotiation: Bringing others together and trying to reconcile differences.
  • Judgment and Decision Making: Considering the relative costs and benefits of potential actions to choose the most appropriate one.
  • Complex Problem Solving: Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
  • Monitoring: Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
  • Social Perceptiveness: Being aware of others' reactions and understanding why they react as they do.

Job Zones

  • Considerable Preparation Needed
  • Education: Most of these occupations require a four-year bachelor's degree, but some do not.
  • Related Experience: A considerable amount of work-related skill, knowledge, or experience is needed for these occupations. For example, an accountant must complete four years of college and work for several years in accounting to be considered qualified.
  • Job Training: Employees in these occupations usually need several years of work-related experience, on-the-job training, and/or vocational training.
  • Job Zone Examples: Many of these occupations involve coordinating, supervising, managing, or training others. Examples include accountants, sales managers, database administrators, teachers, chemists, environmental engineers, criminal investigators, and special agents.
  • Specific Vocational Preparation in years: (7.0 to < 8.0)

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