How to Be Claims Case Manager - Job Description, Skills, and Interview Questions

Feb 18, 2020 / 6 Minutes Read / By Albert

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The increasing number of insurance claims has caused a need for additional Claims Case Managers. These professionals are responsible for assessing the validity of claims, determining the appropriate settlement amount, and negotiating with claimants to assess their needs. Claims Case Managers must be knowledgeable about relevant laws, regulations, and industry practices, as well as have strong communication and negotiation skills.

In addition, they must have an in-depth understanding of the claims process and be able to accurately analyze and evaluate data. The presence of Claims Case Managers has led to a more efficient claims process, with fewer errors and discrepancies, resulting in satisfied customers and improved customer service.

Steps How to Become

Obtain a Bachelor's Degree. The first step to becoming a Claims Case Manager is to obtain a bachelor's degree in a related field. This could include a degree in social work, psychology, sociology, or another related field.
Get Certified. Many employers prefer candidates who have obtained certification in case management. The National Institute for Case Management (NICM) offers certification for case managers.
Gain Experience. Most employers require applicants to have at least two years of experience in a related field. This could include experience as a social worker, psychologist, or another related field.
Apply for Jobs. After obtaining the necessary credentials, the next step is to apply for jobs as a claims case manager. As with any job search, make sure to research the company and have a good understanding of the position before applying.
Pass a Background Check. As with any position that involves dealing with sensitive information, employers will likely require candidates to pass a background check. Make sure to have any relevant information available in case it is needed.

The task of a Claims Case Manager is to efficiently and effectively manage claims. This involves a number of steps, such as gathering evidence, reviewing documents, conducting interviews, and negotiating settlements. In order to be successful in this role, it is important to have good organizational skills and the ability to think critically and find creative solutions to complex problems.

strong communication skills are essential in order to effectively interact with clients and build trust. an effective Claims Case Manager must be able to quickly assess the situation and determine the best course of action to achieve a successful resolution.

You may want to check Case Investigator, Case Load Manager, and Home Care Case Manager for alternative.

Job Description

Handle inbound and outbound calls from claimants and other parties concerning claims issues
Gather and analyze information from claimants, employers, medical providers, and other sources
Provide accurate and timely information to claimants and other parties
Perform investigations to obtain additional information related to claims
Monitor claims progress and ensure timely resolution
Review and process claims documents as required
Maintain up-to-date records of all claims activity
Resolve disputes with claimants, employers, and other parties
Handle appeals and other requests for reconsideration
Provide customer service support to claimants and other parties
Prepare reports and other documents as required
Assess potential fraud and take appropriate action
Communicate with internal departments to coordinate services for claimants
Utilize claims systems and other related applications

Skills and Competencies to Have

Communication: Ability to communicate effectively both verbally and in writing with all levels of staff, clients, and external stakeholders.
Emotional Intelligence: Ability to stay composed throughout stressful situations and maintain a professional manner.
Attention to Detail: Ability to accurately review, analyze, and interpret information.
Problem Solving: Ability to quickly identify and resolve issues.
Time Management: Ability to manage multiple tasks and prioritize workload in order to meet deadlines.
Interpersonal Skills: Ability to build relationships with clients and colleagues.
Negotiation Skills: Ability to negotiate with external parties in order to reach the best outcome for the client.
Technical Knowledge: Knowledge of relevant laws, regulations, and processes related to claims management.
Decision-Making: Ability to evaluate data and make sound decisions in a timely manner.
Adaptability: Ability to adjust quickly to changing circumstances and take advantage of new opportunities.

The most important skill for a Claims Case Manager is the ability to effectively manage and investigate complex cases. This requires being able to analyze large amounts of data and use critical thinking skills to make accurate decisions. In addition, a successful Claims Case Manager must possess excellent communication and customer service skills in order to effectively work with clients and other insurance professionals.

They must also have the ability to remain organized and keep track of case files and paperwork in order to ensure that all cases are handled efficiently and accurately. Finally, a Claims Case Manager must be able to effectively manage their time and prioritize tasks, as they often have multiple cases going on simultaneously. All of these skills, when combined, help ensure that a Claims Case Manager can successfully investigate and manage cases in order to provide the best possible outcome for their clients.

Patient Care Case Manager, Utilization Review Case Manager, and Refugee Resettlement Case Manager are related jobs you may like.

Frequent Interview Questions

What experience do you have with processing and adjudicating claims?
How do you stay up to date on changes in claims regulations?
Describe a time when you successfully negotiated a difficult claim situation.
What strategies do you use to ensure accuracy and compliance with claims regulations?
In what ways do you prioritize claims to ensure timely processing?
How would you handle a situation when a claimant has multiple claims?
What steps do you take to ensure claimants are provided with appropriate coverage?
How do you work with other departments to ensure accuracy in claims processing?
What methods do you use to keep track of claim statuses and progress?
Describe a situation in which you have had to explain complex claim process and regulations to a customer.

Common Tools in Industry

Case Management Software. This software helps to organize, track, manage and analyze case information. Example: LexisNexis CaseMap.
Document Management System. This system helps to organize, store, and manage documents related to claims. Example: DocuSign.
Data Analysis Tools. These tools help to analyze data associated with claims, such as medical records and other relevant documents. Example: SPSS Statistics.
Communication Tools. These tools help to streamline communication between claims departments and other internal and external stakeholders. Example: Slack.
Reporting Tools. These tools help to generate reports on a variety of claims-related data. Example: Tableau.

Professional Organizations to Know

Risk and Insurance Management Society (RIMS)
Chartered Insurance Institute (CII)
International Institute of Loss Adjusters (IILA)
Association of Professional Insurance Women (APIW)
National Association of Professional Surplus Lines Offices (NAPSLO)
American Association for Justice (AAJ)
Society of Claim Law Associates (SCLA)
Association of Risk Management Professionals (ARMP)
American Society of Claim Professionals (ASCP)
Professional Liability Underwriting Society (PLUS)

We also have Commercial Case Manager, Case Manager, and Clinical Case Manager jobs reports.

Common Important Terms

Claim. A demand for payment or other compensation from an insurer to a policyholder, medical provider, or other eligible claimant.
Liability Insurance. Insurance that protects an individual or business from the financial consequences of being found liable for a claim.
Negligence. The failure to exercise the degree of care that would be expected of a reasonable and prudent person in similar circumstances.
Subrogation. The process by which an insurance company steps into the shoes of a claimant and takes legal action against the negligent party in order to recoup the funds it paid out to the claimant.
Statutes of Limitations. Laws that set a time limit on how long a person can wait before filing a lawsuit or making a claim for compensation.
Pre-Existing Conditions. Medical conditions that existed before an individual purchased an insurance policy or requested coverage for a particular condition.
Mediation. A dispute resolution process in which a neutral third-party attempts to help the parties reach an agreement without going to court.
Settlement Agreement. An agreement between the insured and the insurance company in which the insured agrees to accept a lump sum payment in exchange for dropping the claim or waiving any further rights to pursue legal action against the insurer.

Frequently Asked Questions

What is a Claims Case Manager?

A Claims Case Manager is a professional responsible for managing the process of filing and settling insurance claims. They may assess claims, investigate the circumstances surrounding them, negotiate settlements with claimants and insurers, and ensure that all documentation is accurate and up-to-date.

What qualifications are required to become a Claims Case Manager?

A Claims Case Manager typically needs to have a bachelor's degree in a related field such as insurance, finance, or accounting, as well as experience in the insurance industry. Additionally, many employers require certification from organizations such as the Insurance Institute of America or the American Association of Professional Claims Managers.

What are the primary duties of a Claims Case Manager?

The primary duties of a Claims Case Manager include evaluating claims to determine their validity, investigating the facts surrounding each claim to ensure accuracy, negotiating settlements with claimants and insurers, and managing the overall claims process. Additionally, they may be responsible for training staff on insurance industry regulations and processes.

What are some of the most important skills for a Claims Case Manager?

The most important skills for a Claims Case Manager include strong communication and negotiation skills, analytical thinking, attention to detail, and problem-solving abilities. They must also be knowledgeable about the insurance industry and its regulations.