Claim approver vs senior claims specialist

Differences between claim approver and senior claims specialist duties and responsibilities

Claim approver example responsibilities.

• Manage confidential medical records and directs them to the appropriate practitioners while ensuring HIPPA regulations are maintain.
• Train new hires on HMO claim processing.
• Provide claim processing information for medical indemnity and PPO plans.
• Present clinical management appeals for physician review and prepare provider resolution correspondence.
• Submit appeals insurance follow-ups electronically, no fault, and workers compensation insurance.
• Direct litigation in the areas of environmental liability, extra contractual claims, general liability, and medical malpractice.
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Senior claims specialist example responsibilities.

• Manage assigned third party administration (TPA) multi-jurisdictional workers' compensation; subrogation recovery claims; assign defense attorney.
• Work toward settlement with claimants and attorneys, or determine company litigation strategy, participating in mediation and arbitration when necessary.
• Maintain EDI processing table logic.
• Work with testing HIPAA transactions, reporting and processing data reporting to the state.
• Review data entry of claims receive through the EDI system for accuracy prior to processing.
• Operate within all company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines.
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