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Automation Squad

Role

AI for Claims Adjusters

Robert MacKelfresh

By Robert MacKelfresh

Founder, Automation Squad

Review settled claims to determine that payments and settlements are made in accordance with company practices and procedures. Confer with legal counsel on claims requiring litigation. May also settle insurance claims.

Claims Adjusters, Examiners, and Investigators · O*NET 13-1031.00 · Job Zone 4 · sourced from the U.S. Department of Labor occupation database

Automation coverage

8 of 40tools on this list have an AI solution available today

Counted by matching the tools this occupation is documented as using against a corpus of 226,452 AI products, MCP servers, skills and connectors. Where a tool has no match, we say so rather than inventing one.

AI you can use for this job

22 matched to the tools claims adjusters, examiners, and investigators use. Showing 22.

The tools this job actually uses

73 documented for this occupation. Showing 40, hot technologies first. A filled dot means an AI solution exists for it.

  • Apple Safarihot
  • Microsoft Accesshot
  • Microsoft Excelhot
  • Microsoft Office softwarehot
  • Microsoft Outlookhot
  • Microsoft PowerPointhot
  • Microsoft Wordhot
  • Mozilla Firefoxhot
  • Zoomhot
  • 4n6xprt Systems StiffCalcs
  • ADP software
  • Agency Management Systems AMS 360
  • ARSoftware WinSMAC
  • AutoClaims Direct DirectLink
  • Automatic Data Processing Autosource
  • Automatic Data Processing Claims Manager & Dispatch
  • Automatic Data Processing Estimating
  • Axonwave Fraud and Abuse Management System
  • BCCORP Burkitt W5
  • BCCORP W5 for Adjusters
  • Bill review software
  • Bramerhill ClaimsTech
  • Bridium Claims 3
  • Brightwork Alyce Claims Systems
  • Business software applications
  • CAD Zone Insurance
  • Captiva InputAccel
  • Castek Insure3 Claims
  • CCC EZNet electronic communications network
  • CCC GuidePost Decision Support
  • CCC Pathways Appraisal Quality Solution
  • CCC Pathways Image Management Solution
  • CCC TL2000 Solution
  • CGI-AMS BureauLink Enterprise
  • CGI INSideOUT
  • Claims processing administration and management software
  • Clear Technology Tranzax
  • Computerized voice stress analyzer CVSA software
  • Corporate Systems ClaimsPro
  • Covansys ClaimConnect

What this job involves

29 documented tasks, most important first. Showing 24.

  1. Examine claims forms and other records to determine insurance coverage.
  2. Analyze information gathered by investigation and report findings and recommendations.
  3. Pay and process claims within designated authority level.
  4. Investigate, evaluate, and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.
  5. Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
  6. Review police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.
  7. Investigate and assess damage to property and create or review property damage estimates.
  8. Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.
  9. Interview or correspond with claimants, witnesses, police, physicians, or other relevant parties to determine claim settlement, denial, or review.
  10. Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.
  11. Resolve complex, severe exposure claims, using high service oriented file handling.
  12. Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
  13. Confer with legal counsel on claims requiring litigation.
  14. Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.
  15. Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
  16. Refer questionable claims to investigator or claims adjuster for investigation or settlement.
  17. Collect evidence to support contested claims in court.
  18. Supervise claims adjusters to ensure that adjusters have followed proper methods.
  19. Contact or interview claimants, doctors, medical specialists, or employers to get additional information.
  20. Conduct detailed bill reviews to implement sound litigation management and expense control.
  21. Communicate with reinsurance brokers to obtain information necessary for processing claims.
  22. Present cases and participate in their discussion at claim committee meetings.
  23. Report overpayments, underpayments, and other irregularities.
  24. Attend mediations or trials.
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