What Does A Claims Administrator Do?

WHAT DOES A CLAIMS ADMINISTRATOR DO?

The Claims Administrator manages a portfolio of long-term claims, ensures timely benefit payments, and undertakes customer service and administration activities for the Direct and Retail claims function. This role involves responding to inquiries from claimants and representatives through calls and emails, making proactive outbound calls for follow-up, and managing relationships while monitoring service delivery and quality. Additionally, the administrator liaises with various internal departments, ensures compliance with policies and regulations, and participates in business and company projects, maintaining a commitment to Customer Service Culture.

A Review of Professional Skills and Functions for Claims Administrator

1. Claims Administrator Responsibilities

Damage Claims Management: Managing and processing damage claims from clients as a result of the wide-ranging activities through to the best settlement.
Utility Damage Claims Management: Managing and processing utility damage claims (gas, water, power) from third parties as a result of the company's activities through to the best settlement.
Insurance and Legal Coordination: Coordinating and managing interfaces with insurance stakeholders and legal representation about personal injury claims.
Subcontractor Liaison: Liaising with subcontractors/suppliers about contra charges and other interfaces relating to recharging claims back to the suppliers.
Third-Party Claims Liaison: Liaising with third parties on behalf of suppliers to enable the best settlement outcome for the company and supply chain stakeholders.
Penalties and Defects Coordination: Coordinating and recharging LA fixed penalties, S74s, and defects management.
Claims Management and Resolution: Managing claims and liaising with Management to find the best resolution.
Complaints Department Interface: Interface and work closely with the existing complaints department and support.
Ad Hoc Reporting: Create ad hoc correspondence and reports for members, producers, and external partners.

2. Claims Administrator Accountabilities

Support and Development: Provide support and develop information useful for insurance renewals and self-insurance applications.
Risk Assessment: Assist in assessing risks and recommending program alternatives to reduce and mitigate losses.
Policy Development: Develop policies and procedures relating to the efficient administration of various claims management programs.
Claims Management: Responsible for managing claims and making settlement recommendations to the Office of the General Counsel and other relevant staff.
Facility Knowledge Maintenance: Maintains extensive knowledge of all Authority facilities, including the condition and site-specific risks associated with the same.
Claims Reporting Procedures: Establish consistent reporting and follow-up procedures for all claims involving customers, employees, and Authority equipment or property.
Database Maintenance: Maintain Authority database and conduct monthly reconciliation of vendor invoices and statements for all insurance and benefit programs.
Quality Assurance: Ensures quality assurance and vendor compliance by conducting site reviews of claim files and procedural audits.
Vendor Relations: Serves as Authority representative to various carriers, TPAs, and vendors to resolve billing, claim, and administrative issues.
Accident Evaluation: Evaluate accident and claim trends to develop proactive corrective measures.

3. Claims Administrator Functions

Accident Investigation: Undertakes appropriate investigations of recurring accidents to ascertain root causes and possible preventative measures that can be implemented.
Injury Incident Investigation: Investigates employee and customer injury incidents to determine validity and liability.
Claims Monitoring: Monitors claims and where appropriate forwards to third-party administrator.
Property Damage Investigation: Investigates property damage incidents to determine validity and liability.
Subrogation Identification: Identifies areas for third-party recovery subrogation and recovery of monetary damages.
Claims Processing: Processes self-insured damage claims timely.
Benefits Claims Processing: Processes ADA, FMLA, MLOA, and STD/LTD claims.
Self-Insurance Program Management: Monitors management of self-insurance programs by budgeting and reviewing payments to claimants and attorneys.
Reserve Establishment: Establishes reserves with feedback from counsel and third-party administrators.
Claims Invoice Review: Reviews monthly claims disbursement invoices for accuracy and submits for payment approval.

4. Claims Administrator Job Description

Financial Reporting Skills: Reviews monthly Loss Run reports for accuracy and submits general liability reserve and workers’ compensation reserve information with appropriate allocation of departmental charges to Finance.
Data Management Skills: Maintains, organizes, and prepares loss data for various reports and ensures proper communication of pertinent data with various levels of management and auditors.
Legal Preparation Skills: Prepares litigated cases for the Authority’s defense and forwards those claims to house counsel.
Legal Assistance Skills: Assists legal counsel in the investigation and defense and assertion of claims and the coordination and assembly of responses to legal pleadings on behalf of the Authority.
Insurance Reporting Skills: Reports automobile incidents to appropriate insurance carriers to protect the interests of the Authority.
Damage Recovery Skills: Recovers monetary damages from others for property damage caused by them to Authority property.
Dispute Resolution Support Skills: Assists in gathering information in any type of alternative dispute resolution.
Trend Analysis: Identifies trends and makes recommendations to the appropriate party for improvement.
Compliance Training Skills: Provides training and education relating to compliance with work injuries, leaves, disabilities, liabilities, and other work injury claims.

5. Claims Administrator Overview

Claims Handling and Administrative Support: Provide claims handling and administrative support
Claims Recording and Processing: Record and process new and existing claims
Interdepartmental Liaison: Liaise with Loss Adjusters, Brokers, Policyholders, and Solicitors
Claim Payment Processing: Process claim payment requests and pass for approval
System Utilization: Utilize systems such as IRIS, CRU, and Bordereaux
General Administration: Carry out general administration duties
Claims Submission Assistance: Assist in customer claim submissions to ensure completeness and accuracy
Customer Communication: Communicate with customers via phone and email to help gather missing details and support documentation
Information Verification and Updating: Verify and update information needed on claims
Claim Monitoring and Reporting: Monitor claim status and generate reports through the database
Customer Interaction and Support: Conduct weekly calls with customers to update and/or answer any questions they may have

6. Claims Administrator Details and Accountabilities

Workplace Communication: Communicating with co-workers and supervisors
External Development: Developing external entities for information needed to process pending claims
Feedback Reception: Receiving technical feedback from management and the technical staff
Improvement Identification: Providing potential improvement opportunities to management or the technical staff
Claims Data Entry: Data entry of hard-copy claims
Production Standards Achievement: After the end of the learning curve, produce at or above acceptable production standards
Online Edits Resolution: Resolve fundamental, online edits
Batch Edits Resolution: Resolve edits on claims suspending on batch edits
Production Standards Achievement: After the end of the learning curve, produce at or above acceptable production standards
Fundamental Edits Resolution: Resolve fundamental edits including making basic mathematical calculations, researching the Internet or Intranets, etc.
Quality Maintenance: Maintain an acceptable quality level
Quality and Performance Achievement: Meet or exceed the minimum levels for quality as measured by the Quality and Performance Management department and by the Claims Department

7. Claims Administrator Tasks

Team Collaboration: Work as part of the Team to process and approve all aspects of the workload to the required quality and timescales
Management Reporting: Provision of management information including associated follow-up tasks and reporting
System Development: Contribute to the development of the systems and processes individually and through the wider work of the Team to achieve an effective and efficient end-to-end process
Project Coordination: Co-ordinate the timely delivery of project information, to ensure effective management and control of the projects
Project Management: Ensure that projects are started in a controlled manner, monitored effectively and efficiently with issues resolved quickly, and closed out promptly
Procedure Management: Maintain, develop and improve project start-up, in-life and project close procedures including issues escalation and management
Process Improvement Assistance: Assist with the process improvement of the monitoring function information systems
Operations Support: Work with Innovate Operations Delivery teams to deliver and improve continuously the processes for the engagement of MOs and MLOs
Process Ownership: Develop and be responsible for processes for monitoring, budgeting and planning, and support management of the budget
Change Request Management: Review and process Project Change Requests, ensuring effective completion
Innovative Support: Support other elements of innovative delivery, as well as ad-hoc project work

8. Claims Administrator Roles

Portfolio Management: Managing a portfolio of long-term claims and ensuring benefit payments are made on time
Customer Service: Undertake customer service and administration activities in support of the Direct and Retail claims function
Inquiry Response: Respond to all inquiries from claimants and representatives, including telephone calls and emails
Proactive Communication: Make proactive outbound telephone calls to claimants/representatives for follow-up and information
Relationship Management: Proactively manage relationships whilst monitoring service delivery and quality
Internal Liaison: Liaise closely across the Claims and other relevant internal departments to provide support
Regulatory Compliance: Ensure compliance with policies and procedures, as well as external regulations
Stakeholder Interaction: Ensure all interactions with internal and external stakeholders adhere to Customer Service Culture
Project Participation: Participate in the business area and/or company projects

9. Claims Administrator Additional Details

Pollution Claims Management: Responsible for overseeing and managing pollution coverage claims through the entire life cycle, from incident notification to completion of work.
Claims Investigation: Responsible for investigating and evaluating claims (with a heavy emphasis on pollution coverage claims).
Claims Handling Quality Assurance: Provides quality claim handling following established procedures throughout the claim life cycle and ensures file quality and timely claim analysis and communication with claimants.
Loss Investigation: Establishes facts of loss, investigation, and damage assessment.
Claims Decision Making: Exercises proper judgment and decision-making to analyze claims, and provides recommendations about claims handling.
Claims Review: Proactively reviews Claim Files for adherence to quality standards and trend analysis.
Legal Expense Management: Tracks and controls legal expenses to ensure cost-effective resolution.
Claims Disposition: Responsible for the prompt and proper disposition of all claims within the delegation of authority.
Recovery Evaluation and Management: Evaluate all claims for recovery potential, directly handle recovery efforts and/or engage and direct Company resources for recovery efforts.
Community Management Support: Provides support to Community Management to ensure prompt, accurate, and appropriate communication with Residents.

10. Claims Administrator Role Purpose

Pre-claim Screening: Responsible for pre-claim screening
Claim Department Determination: Determining if a claim should be handled by guest claims or another department
Insurance and Subrogation Analysis: Determining what insurance coverage or subrogation options we have for the specific claim
Inter-department Liaison: Act as an inter-department liaison by communicating with other departments about any evidence or testimony that needs to be collected
Marketing Suppression Management: Directing marketing to add litigants to the marketing suppression list
Claims Audit: Audit claim files to ensure complaints and that all required information is entered and documentation is included
Claims Reporting: Complete and submit monthly and quarterly claims reports to Medicare
Claims Office Management: Responsible for claim administration office management
Case Conclusion Communication: Communicate concise action plans, and present plans for moving the case to conclusion