Senior claims specialist vs senior claims processor

Differences between senior claims specialist and senior claims processor duties and responsibilities

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.
Show more

Senior claims processor example responsibilities.

• Manage confidential medical records and directs them to the appropriate practitioners while ensuring HIPPA regulations are maintain.
• Investigate, manage, negotiate and resolve claims arising out of accidents involving automobile and homeowner policies.
• Process CalPERS HMO facility claims.
• Experience with HMO's, IPA's and insurance authorizations.
• Handle confidential information according to new laws (HIPPA).
• Review ICD-9 diagnosis codes against CPT codes for claim payment guidelines.
Show more