Claims benefit specialist vs worker's compensation claims examiner

Differences between claims benefit specialist and worker's compensation claims examiner duties and responsibilities

Claims benefit specialist example responsibilities.

• Analyze, process and manage FMLA claims to determine eligibility and certification in compliance with state and federal regulations.
• Establish a working knowledge of CPT, ICD-9, HCPCS codes, terminology, member benefits and claim flow.
• Process claims utilizing appropriate ICD-9, DSM-IV and HCPCS codes.
• Analyze each claim and calculate percentages for both PPO and NON-PPO providers.
• Understand CPT, HCPCS, ICD-9-CM and ICD-10-CM medical claims coding regulations and guidelines
• Process Non-HMO and PPO paper and electronic claims in an accurate and time manner.
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Worker's compensation claims examiner example responsibilities.

• Manage all aspects of claims, including heavy litigation and vocational rehabilitation cases.
• Negotiate settlements and actively manage the litigation process and process complex and technically difficult claims.
• Determine benefits when processing medical claims receive as HCFA and UB92 paper claims or electronically.
• Set up vehicle inspections, and rental reservations as a part of the claim settlement process.
• Handle incoming calls from customers and providers with policy changes and claim status updates and maintain HIPAA.
• Process claim forms, adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements and Medicaid claims.
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