Claims Administrator Job in Irving, TX

Responsibilities:

Claim Intake and Review:
- Receive and review claims submitted by employees, clients, or policyholders.
- Ensure that claims are complete, accurate, and meet the criteria for coverage.
- Verify all necessary documentation is included and initiate follow-up for missing information.
Claims Processing:
- Process and evaluate claims for approval or denial based on company policies, insurance contracts, or service agreements.
- Review medical, accident, or other relevant information to assess the validity and value of the claim.
- Update and maintain claims records in the system for tracking and auditing purposes.
Communication with Stakeholders:
- Communicate with claimants (employees, customers, vendors) to inform them of claim status and gather additional information if needed.
- Respond to questions from claimants and other stakeholders regarding claim progress and outcomes.
- Work with insurance carriers, third-party administrators, or legal teams when necessary.
Investigation and Analysis:
- Investigate the details of complex claims and conduct research to verify the accuracy of the claim.
- Analyze the severity and validity of claims to make determinations on approvals or denials.
- Coordinate with medical professionals, law enforcement, or other specialists as needed for thorough investigation.
Claims Resolution and Settlement:
- Work to resolve claims efficiently, ensuring all details are correctly documented and payments are processed in a timely manner.
- Negotiate settlements when applicable, ensuring compliance with company policies and legal requirements.
- Process claims payments, track any pending or disputed claims, and follow up on unresolved issues.
Record Keeping and Documentation:
- Maintain accurate, detailed, and organized records of all claims, correspondence, and settlement activities.
- Prepare reports on claim status, trends, and financial summaries for management and auditing purposes.
Compliance and Regulations:
- Ensure that claims processing complies with internal policies, industry standards, and regulatory requirements.
- Keep up to date on any legal or regulatory changes related to claims administration.
Customer Service and Support:
- Provide a high level of customer service by addressing claimant concerns and inquiries in a timely, professional manner.
- Offer guidance on the claims process and ensure a positive experience for claimants.
Continuous Improvement:
- Recommend improvements to claim processes, systems, or policies based on feedback or identified inefficiencies.
- Participate in training and development opportunities to stay current on best practices and changes in the industry.

Skills and Qualifications:

Strong attention to detail and organizational skills.
Excellent communication skills for interacting with claimants and other stakeholders.
Knowledge of insurance policies claims processing, and legal regulations.
Ability to handle confidential and sensitive information with discretion.
Proficiency with claims management software and tools.
Problem-solving skills and the ability to make sound decisions.
Ability to work under pressure and manage multiple claims simultaneously.