What Are the Duties of a Claim Processor?
Whether the specialty is auto, health, life, or disability insurance, claim processors contribute greatly to the success of the insurance industry. The role of the claim processor in an organization is, on its most basic level, to pay or deny insurance claims promptly and accurately.
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How Claims Reach Insurance Companies
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Once insurance claims reach an insurance company by mail, these documents are scanned and uploaded onto a centralized image viewing system for claim processors and other relevant staff to access. The most productive time in the life cycle of a claim, however, is its time spent on the virtual or real desktop of a claim processor--this is where the rubber meets the road, so to speak.
How Claims Reach Claim Processors
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Claims received by an insurance company are usually distributed to claim processors through a role-based access system (RBAC). This system matches claims with claim processors based on criteria such as whether the claim is being submitted for the first time, or if it is being submitted as an appeal to a previous denial.
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A Virtually Paperless Work Environment
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With RBAC and auto-adjudication (auto-adjudication = a process that enables a claim to pay/deny without processor intervention) technologies revolutionizing how claims are handled, the claim processor that physically handles a paper claim is becoming obsolete.
One exception to the paperless work environment is claims that require in-depth research. These claim-types are usually identified by the department claims are addressed to and routed to the appropriate claim department, in paper format. This too is changing as the rest of the industry changes.
Examining Claim Information
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Claim processor receives a claim, he examines it to determine whether or not the customer is covered by the insurance carrier (the claim processor's employer). This is the most important step, since the claim payment/pending/denial process would end here if the customer is not a covered policy holder.
Other items of importance to a claim processor examining a claim are the incident/service dates and whether or not a claim was filed in a timely manner (timely filing is determined by the insurance company). The items of importance vary by industry, of course, so if you are considering the auto insurance industry, certain criteria such as whether or not the insured is "at fault" might be part of your criteria.
Deciding Whether to Pay, Pend or Deny a Claim
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If a claim processor has determined that all information received is accurate and if no additional system indicators arise, signaling him to investigate further, the next thing a processor does is finalize (make a decision on, and close or pend) the claim. Adequate training is usually provided before a claim processor is expected to finalize a claim, thereby leading to a more informed decision. Training teaches the processor how to apply the most current federal and claim processing guidelines.
Depending on the claim payment software a claim processor uses, finalizing a claim is usually done in a series of steps that place the claim in a status that would result in either the issuance of a check, a letter/phone call asking for additional information, or a claim denial.
Key Elements of Claim Processing/Skills Required
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Skills required of a claim processor are often given general descriptions that tell the applicant everything they need to know in order to get the job, but mention very little about what is required to keep it.
Another valuable skill is the claim processor's ability to explain the rationale behind their claim payment/denial decision, especially if an unconventional method (outside of the usual policies and procedures) was used to finalize the claim.
Be accountable. While not limited to work-related matters, the ability to own up to errors, and take the steps needed to correct mistakes while on the job is another critical function of a claim processor.
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