Customer Service / Service Orientation
Understands principles and processes for providing customer services. This includes customer needs assessment, meeting quality standards for services, approaching conversations with empathy, managing conflict, and keeping customers informed.
Seeks support for building rapport and resolving any conflict.
Asks clarifying questions and engages with customers in a transactional manner.
Listens to the customer and does not make them repeat themselves.
Interacts with mostly internal stakeholders, in a highly supported manner.
Uses clear and concise verbal and written communication to build rapport and resolve conflict.
Asks clarifying questions, practices active listening, and demonstrates empathy when needed.
Meets basic customer needs and identifies the proper employee to help with more complex needs.
Communications are highly structured and pre-planned, with low-risk internal and external stakeholders.
Interacts and communicates with customers to maintain rapport and deescalate conflict.
Responds to customers with appropriate emotions including demonstrating empathy and sympathy, when needed.
Takes ownership of the customer relationship and independently meets customer needs.
Communications with all stakeholders are less structured.
Insurance Claims Principles and Practice
Knows and understands the core principles of insurance and can apply to operations.
Describes what insurance is and what it is used for.
Describes how different departments work together within the organization.
Differentiates between which factors can affect the compensability of claims.
Describes the regulations and rules that govern claims-related decision making.
Narrates the claims process from the start to the close of a claim.
Demonstrates knowledge of compensability factors and appropriate steps for when a loss has occurred and a claim has been accepted.
Leverages knowledge of the claims process to serve as a partner in decision-making.
Uses company processes and state policies to facilitate claims processing for policyholders by gathering or requesting information, managing records, corresponding with stakeholders to manage and resolve open claims, identifying compensability red flags, and approving payments.
Reviews claim documents for accuracy and completion.
Reviews claim documents for accuracy and completion and requests needed information from stakeholders at multiple touchpoints throughout the life of the claim.
Initiates communication with stakeholders.
Examines completed documents for red flags related to compensability and escalates issues accordingly.
Arranges care and manages documents and records appropriately.
Approves payments on bills related to a claim.
Both initiates and responds to communication with and requests from stakeholders.
Confidential Information Handling
Ensures the privacy of client data and confidential situations at all times.
Articulates the importance of upholding confidentiality standards and the consequences for not upholding them.
Upholds confidentiality standards and shows extreme caution when handling sensitive information.
Follows data protection protocols (e.g., locks their computer, encrypts data as appropriate).
Upholds confidentiality standards independently and without referencing policy documents.
Identifies risks to confidentiality and makes suggestions for how to further protect confidentiality.
Effectively uses the claims system to perform essential job functions.
Accesses records and documents for review in appropriate claims handling systems.
Manages documents and records in appropriate claims handling systems.
Accesses, manages, and modifies documents, forms, and records in appropriate claims handling systems.
Reads, aggregates, distills, and disseminates internal and external data to perform essential job functions.
Describes different business operations reports (e.g., customer service, Human Resources, core operations for manufacturing) and how to access them.
Accesses data from different business operations reports.
Knows where to find data for assigned tasks.
Runs reports for internal and external purposes.
Analyzes and processes complex data for core business operations. Identifies the underlying principles, reasons, and facts of data sets. Breaks down information or data into separate parts.
Performs routine data entry tasks to support supervisor.
Exhibits basic navigation of Excel; understands the structure and purpose of a cell.
Reviews data to identify patterns.
Independently performs data entry tasks.
Employs formatting, conditional formatting, and simple formulas in Excel.
Reviews data to identify patterns, trends, anomalies, and outliers.
Writes formulas in Excel and creates pivot tables.
Acts as a steward of data; prepares data with minimal errors for use by colleagues and supervisors.
Analyzes data and trends to inform decisions within the scope of their role.