Home office claims examiner vs claims benefit specialist

Differences between home office claims examiner and claims benefit specialist duties and responsibilities

Home office claims examiner example responsibilities.

• Investigate, manage, negotiate and resolve claims arising out of accidents involving automobile and homeowner policies.
• Review and approve new applications in accordance to CIP guidelines.
• Provide technical support and direction as to case management, experts, litigation management and final authority on reportable claims.
• Participate in business process redesign in claims and litigation.
• Provide oversight for quarterly system testing ensuring system integrity are not compromise by directing consistent testing practices across multiple groups.
• Negotiate settlements and file arbitration or hire counsel when warrant.

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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