WHAT DOES A CLAIMS ANALYST DO?

The Claims Analyst oversees healthcare claim processing and collaborates with physicians to implement tailored healthcare programs. Coverage decisions are assessed based on policy guidelines and medical information, ensuring claims are processed with accuracy and adherence to established turnaround times. Additionally, serves as a resource for resolving member issues and supporting end-of-contract needs as directed by management.

A Review of Professional Skills and Functions for Claims Analyst

1. Claims Analyst Duties

  • Quality and Production Maintenance: Develop skills and maintain all quality, production, and turnaround standards.
  • Relationship Management: Maintain good working relations with all internal and external contacts to ensure an optimal level of service.
  • Claims Research: Research and document information as needed to process claims.
  • Cross-Departmental Collaboration: Work with other departments within the organization to provide resolution.
  • Claims Pattern Analysis: Participate in the research, validation, and resolution of new claims patterns.
  • Report Preparation: Prepare and send monthly GL incident/claim count reports to various insureds for use by Risk Management committees.
  • Customer Support: Answer and/or return "routine" claim calls and inquiries to support claim staff when out of office, with remote assistance from claim staff when necessary.
  • Adaptive Workload Management: Address additional items as needed daily based on claim department workload.
  • Information System Development: Develop and maintain manual and automated information systems in line with all mandatory and regulatory requirements.

2. Claims Analyst Details

  • Information Gathering: Identify, specify, collect, and validate information requirements from a range of sources.
  • Information Facilitation: Facilitate the production of relevant management information.
  • Claims Management: Manage technical and complex claims arrangements efficiently and effectively.
  • Complex Analysis: Conduct complex analyses using appropriate methods and tools.
  • Report Production: Facilitate the production of timely, accurate, insightful, and focused management information solutions and reports.
  • Support Delivery: Support the effective delivery of management information.
  • Relationship Building: Build and maintain relationships with internal customers to define information requirements and ensure associated management information solutions and reports are fit for purpose.
  • Coaching: Provide advice, guidance, and coaching to less qualified and/or experienced colleagues.
  • Community Improvement: Raise standards and expertise across the information management community.

3. Claims Analyst Responsibilities

  • Claims Reporting: Report non-complex claims to carrier and enter reports into the system.
  • Carrier Liaison: Act as a liaison between carrier and insured for all relevant information.
  • Data Retrieval: Obtain loss runs in PDF and Excel format when available from the carrier according to deadlines already established for the meeting/report schedule for the year.
  • Data Analysis: Complete trending and various loss calculations using tools such as pivot tables and charts in Excel.
  • Claim Monitoring: Obtain updates and monitor the status of small non-complex claims (i.e., Auto, property, general liability, med only, blanket accident); update clients throughout the life of the claim.
  • Claim Closure Communication: Obtain claim file closing notices from the carrier, update the client and Claim system.
  • Presentation Preparation: Prepare and bind presentation books, reports, etc.
  • Report Generation: Prepare and send monthly WC incident/claim count reports to various insureds for use by workplace safety committees.

4. Claims Analyst Accountabilities

  • Collections Management: Initiate and handle the customer collections process for accounts in arrear.
  • Payment Oversight: Ensure payment arrangements are kept while minimizing impact to Enbridge.
  • Account Monitoring: Monitor all contract customer accounts and their collection status.
  • Database Integrity: Maintain the integrity of the Collections Database to ensure the accuracy and status of customer activities.
  • Customer Engagement: Engages with the customer to understand the magnitude of damages and amounts owing.
  • Fund Allocation: Allocate the funds received by completing the appropriate ledger transaction in the system.
  • Insurance Collaboration: Work with insurance companies on new and outstanding claims.
  • System Testing: Performs claims systems testing and/or system analysis.
  • System Accuracy: Ensure accuracy of the system’s configuration and provider payments.
  • Risk Reporting: Consolidate the risk exposure reporting for all parties such as Customer Support, Sales, Executives, and Finance.

5. Claims Analyst Functions

  • Health Services Coordination: Plan and coordinate health services.
  • Collaborative Program Implementation: Work collaboratively with physicians to implement appropriate healthcare programs.
  • Claims Processing: Process patient healthcare claims.
  • Policy Enforcement: Establish and enforce healthcare policies and procedures.
  • Coverage Decision-Making: Determine whether to accept or deny coverage for patients based on policy guidelines, diagnoses, and the services that were provided.
  • Quality Claims Processing: Process claims in a production and quality role by accurately coding.
  • Data Management: Review and key data in accordance with defined turnaround expectations.
  • Error Resolution Support: Support member error resolution and multi-vendor processing.
  • End of Contract Resource: Act as a resource for End of Contract Support as assigned by Management.
  • Policy Adherence: Follow all policies and procedures established for the department.

6. Junior Claims Analyst Job Description

  • Process Ownership: Own the end-to-end process, from initial claims/damage notification to cash recovery.
  • Tool Development: Develop tools with the internal product engineering teams to support the claims process.
  • Claim Issuance: Issue finished vehicle claims to multiple suppliers for transportation escalations.
  • Process Improvement: Drive process improvements to increase cost recovery from suppliers.
  • KPI Management: Support/Lead the creation and management of supplier quality and performance KPIs.
  • Standard Definition: Further define claim and insurance standards.
  • Supplier Communication: Publish vehicle/handling updates to suppliers.
  • Damage Minimization: Work with suppliers to minimize overall transport damage.
  • Repair Coordination: Help coordinate in-network vehicle repairs.
  • Efficiency Optimization: Work on “Lean” initiatives and identify other sourcing efficiencies via benchmarking, competitive quotes, and resourcing.
  • Supplier Relationship Maintenance: Maintain day-to-day supplier relationships, point of contact for all supplier commercial issues.
  • General Support: Help anywhere the company needs support.

7. Claims Analyst Overview

  • Investigative Assessment: Conduct investigations including, but not limited to assessing policy coverage, evaluating liability and damages to determine reasonable values, and establishing reserves.
  • Insured-specific Counseling: Conduct insured-specific problem solving, counseling, and loss control.
  • Legal Collaboration: Appoint, collaborate with, and control defense counsel activities and coordinate case strategy.
  • Settlement Negotiation: Determine settlement value, conduct negotiations to settle claims when appropriate.
  • Claim Defense Direction: Direct investigation and defense of individual claims.
  • Case Preparation: Prepare case summaries with presentation of facts for physician review committee meetings.
  • Legal Conference Participation: Participate in pre-trial and settlement conferences or mediations.
  • Claims Disposition: Evaluate and authorize disposition of claims.
  • Document Review: Obtain and review medical records and financial documents.
  • Stakeholder Correspondence: Correspond with policyholders, attorneys, medical facilities, reinsurers, outside vendors, and insured's employer.

8. Claims Analyst Details and Accountabilities

  • ISO Search Execution: Complete proper ISO searches to summarize and make recommendations on loss history.
  • Task Assessment: Determine if tasks can be completed internally or require the use of a vendor and make the referral if warranted.
  • Investigative Support: Checks, surveillance, and AOE/COE investigative assignments.
  • Vendor Selection: Become aware of the best vendor to use for a given circumstance or jurisdiction.
  • Fraud Reporting: Complete State Fraud Referral request forms with all required data for the specified jurisdiction including: claim summary, red flag indicators, investigation summaries, all parties involved, litigation summary, and claim status or disposition.
  • System Navigation: Navigate through several different TPA/MGA claim systems to retrieve information for ISO searches, SFRs, case referrals to vendors, and to obtain claim and policy information.
  • Project Assistance: Assist SIU Director with projects, reconciliations, writing audit result reports, and handling routine/daily matters in absence.
  • Referral Triage: Triage incoming new referrals to SIU to set objectives and determine if internal handling or vendor utilization.
  • Vendor Relationship Management: Build relationships with SIU vendors and determine which are most effective in results and cost.
  • Claims Processing: Perform all claims processing support functions.

9. Claims Analyst Tasks

  • Relationship Management: Help manage relationships with TPAs, insureds, reinsureds, and reinsurers by working with internal and external accounting and claims personnel.
  • Issue Resolution: Resolve insurance and reinsurance claim issues, billing errors, or other discrepancies with respect to direct claims and reinsurance presentations.
  • Financial Calculation: Perform initial direct claims and reinsurance invoice calculations, including determining the amount of loss payment due and expense payment due if applicable.
  • Policy Identification: Identify the correct Company policy(s) or reinsurance contract(s) that respond to direct claim submissions and/or reinsurance sessions.
  • Submission Management: Manage triage of incoming submissions.
  • Data Entry: Enter financial and other claim data into various computer databases.
  • Correspondence Drafting: Draft claim correspondence and create spreadsheets for financial and claim reporting.
  • Audit Assistance: Assist Litigation Counsel/Director of Claims with audit of claim files maintained by external partners as well as internal customers.
  • Claim Processing: Process, approve or deny claims in accordance with company claim guidelines.
  • Drug Testing Coordination: Conduct Post Accident Drug Testing on all drivers involved in accident/damage claim and report results to Director of Safety.

10. Claims Analyst Duties

  • Claims Tracking & Management: Track and manage all driver accident and vehicle damage claims as well as all associated costs.
  • Insurance Claims Management: Manage various types of insurance claims such as physical damage, cargo, property, and liability claims.
  • Claims Processing: File driver accident claims within the Fleet Response claim system, enter data, update databases with current daily claim information.
  • Coverage Determination: Review claim information and determine level of coverage and report to the appropriate policy carrier.
  • Professional Relationship Maintenance: Maintain professional relationships with assigned insurance adjusters regarding the management of claims.
  • Record Keeping: Maintain accident and damage claim records regarding losses and risk management.
  • Client Liaison: Serve as a liaison between clients and insurance companies regarding losses.
  • Damage Assessment: Review all estimates and photos of damage repair.
  • Vehicle Repair Management: Manage the repair of client vehicles due to accidents or damage claims.
  • Stakeholder Relationship Management: Maintains professional relationships with clients and business partners (both internal and external) regarding the status of accident/damage claims.
Relevant Information
What Does A Claims Administrator Do?