Ajustadores, examinadores e investigadores de reclamaciones

Operaciones empresariales y financieras · Habilidades y competencias laborales · SOC 13-1031 · 201 skills

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▶3 tareas típicas de O*NET

Examine claims forms and other records to determine insurance coverage.
Analyze information gathered by investigation and report findings and recommendations.
Pay and process claims within designated authority level.

Los datos de tareas se han extraído de O*NET® 29.1 Database de USDOL/ETA y se utilizan bajo CC BY 4.0.

warranty-claims-processor

1.6k

a5c-ai/babysitter

Streamlined warranty claim validation and processing skill improving customer satisfaction and reducing processing time

2026-06-01

claims-triage

1.2k

mohitagw15856/pm-claude-skills

Triage an incoming insurance claim: check the coverage trigger against policy wording, band severity and complexity, screen for fraud indicators, set a first-pass reserve range, and route with an SLA. Use when asked to triage a claim, review a first notice of loss (FNOL), assess a new claim, decide fast-track vs adjuster routing, or screen a claim for SIU referral. Produces a structured triage note with coverage view, severity band, indicator screen, reserve range, and a routing recommendation.

2026-07-14

claims-triage

1.2k

mohitagw15856/pm-claude-skills

2026-07-14

coverage-gap-analysis

1.2k

mohitagw15856/pm-claude-skills

Map an organisation's risks against its insurance policy portfolio to find what's uncovered, underinsured, or double-covered. Use when asked to run a coverage gap analysis, review an insurance programme against a risk register, check what risks aren't insured, or audit a policy portfolio. Produces a risk-by-coverage matrix, flagged gaps and overlaps, a deductible stack review, and recommendations ranked by expected-loss severity.

2026-07-14

policy-renewal-review

1.2k

mohitagw15856/pm-claude-skills

Run a pre-renewal review of an insurance programme: scan coverage gaps against current operations, test limit adequacy against inflation and exposure growth, read the claims experience into pricing expectations, frame market alternatives, and arm the broker negotiation. Use when asked to prepare for a policy renewal, review cover before renewal, check if limits are still adequate, or build renewal negotiation points. Produces a structured renewal review with gap findings, limit assessment, pricing outlook, and negotiation points.

2026-07-14

underwriting-narrative

1.2k

mohitagw15856/pm-claude-skills

Write the underwriting file narrative for a risk: the risk story, exposure quantification, loss-history read, mitigating and aggravating factors, terms and subjectivities rationale, appetite fit, and a refer-or-bind recommendation. Use when asked to write up an underwriting file, document why we're writing a risk, prepare a referral to a senior underwriter, or justify terms and exclusions on a submission. Produces a complete underwriting narrative ready for the file or referral.

2026-07-14

the-insurance-adjuster

1.2k

mohitagw15856/pm-claude-skills

Simulate the adjuster's settlement call after your accident or loss — the recorded-statement asks, the quick-settlement anchor, the friendly minimization — run against your actual claim, with a debrief on every answer that shrank it. Use when asked the adjuster wants a recorded statement, practice the settlement call, is this settlement offer low, or what will the insurance company try. Produces the call transcript with the adjuster's file notes, the offer trajectory, and a debrief separating fair process from pressure tactics — plus the bright lines that protect a claim.

2026-07-18

claim-denial-decoder

1.2k

mohitagw15856/pm-claude-skills

保険金の支払拒否通知を解読する——引用された理由が実際何を意味するか、よく覆るタイプかどうか、そして一点ずつ反論する不服申立ての手紙。「保険金請求が拒否された、どうすれば」「この拒否通知を解読して」「この拒否は不服申立てできるか」「保険の不服申立てを書いて」と聞かれたときに使う。覆る見込みの枠組み付きの拒否解読、証拠チェックリスト、一点ずつ反論する申立書、保険会社を越えるエスカレーションの梯子を産出する。

2026-07-18

insurance-policy-decoder

1.2k

mohitagw15856/pm-claude-skills

住宅・賃貸・自動車の保険証券を、必要になる前に、実際に何が補償され、何が除外され、支払いの計算が本当はどうなるかへと解読する。「自分の保険は実際何をカバーしているのか」「証券を解読して」「この免責額は普通か」「実損てん補と再調達価額の違いは」と聞かれたときに使う。実際の支払いシナリオ付きの補償別解読、ランク付けされた除外の危険信号、ACV と再調達価額の計算、更新前に代理店へ聞く質問を産出する。

2026-07-18

travel-insurance-evaluator

558

FerroxLabs/wayland

Creates a travel insurance coverage comparison checklist and explains key policy clauses in plain language. Gathers trip details, traveler health profile, and risk factors to produce a side-by-side coverage comparison framework and a policy clause decoder that highlights what to look for and what exclusions to watch out for. Use when the user asks about travel insurance, how to choose a travel insurance policy, what travel insurance covers, or how to compare travel insurance options. Do NOT use for health insurance selection (use health-wellness or personal-finance skills), auto insurance, home insurance, or life insurance comparison.

2026-06-07

outpatient-coverage-scope-judgment-assistant

211

aifinlab/FinClaw

当用户需要判断保险理赔案件中的门诊场景是否可能落入保险责任范围、结合保单和条款分析门诊费用能否赔、识别免责限制因素、评估材料是否足以支持门诊责任判断或输出适合理赔审核与复核使用的门诊责任判断意见时使用本 skill。适用于分析理赔系统案件记录、报案信息、门诊病历、诊断证明、处方单、检查检验报告、医疗发票、费用清单、医保结算单、用药记录、客服或审核备注、OCR 文本、PDF 文档和截图转写内容，并结合产品责任、等待期、医院范围、赔付比例、免赔额、限额、医保目录限制、既往症和免责条款形成结构化初步判断。

2026-03-26

afrexai-insurance-automation

FDU-INS/Insurance-Skills

Insurance Operations Automation

2026-05-18