Claims Examiner Job Description

Claims Examiner Job Description, Skills, and Salary

Are you searching for a claims examiner job description? Get to know about the duties, responsibilities, qualifications, and skills requirements of a claims examiner. Feel free to use our claims examiner job description template to produce your own claims examiner job description. We also provide you with information about the salary you can earn as a claims examiner.

 

Who is a Claims Examiner?

A claims examiner is a member of the insurance company who reviews claims that have been resolved by the insurance adjuster, enters claims as inventory entries, investigates disputed claims, compiles reports on claims for the business, and takes part in claims-related litigation after consulting with legal counsel. After they are submitted, claims are reviewed by claims examiners to make sure claimants and adjusters adhere to the correct procedures. They could help adjusters with challenging claims or, for instance, when a natural disaster increases the number of claims.

 

Health insurance company examiners assess medical claims to see whether the charges are appropriate given the diagnosis. After reviewing the claim, they decide whether to approve the payment in the proper amount, reject the claim, or submit it to an investigator.

Because most life insurance companies give additional benefits if a death is accidental, examiners who work for life insurance firms analyze the causes of death and pay particular attention to accidents. Examiners may also look into fresh life insurance policy applications to make sure the applicants don’t have any major conditions that would make them difficult to insure.

Insurance claims are examined by claims examiners to ensure that the proper procedures were followed in the investigation and reporting of claims by both claimants and claim adjusters. Claims examiners check for conformity with the law, accept or reject insurance claims, and aid claim adjusters as necessary.

To prevent unnecessary financial loss for insurers claim examiners analyze insurance claims and applications and monitor the progress of insurance adjusters.

 

Claims inundate an insurance provider. A claims adjuster settles the majority of these. The claims examiner approves every claim. The claims examiner has a responsibility to resolve claims in the insurance company’s best interest. That is merely one of the many tasks that a claims examiner is assigned.

When it comes to claims, the claims examiner must also be alert for any abnormalities and always keep an eye out for overspending and underspending. The claims examiner doesn’t just submit a report when they come across a dubious claim. They must look into it. It might also entail seeking advice from other experts. For example, the claims examiner would speak with a doctor about a medical claim to determine its viability. The claims examiner makes a recommendation to the insurance company when it decides to pursue a claim against a policyholder. The claim examiner and the legal counsel collaborate on the case during the litigation process.

In the insurance sector, claim examiners check the veracity of insurance claims. Examiners of claims examine them after submission to ensure that all parties involved followed the correct procedures. These specialists are prevalent in the health and life insurance industries. After reviewing the claim, they decide whether to accept it or reject it. To evaluate whether a person would be a high-risk person to cover, they may also examine the claims of those applying for life insurance policies.

 

A clerk who checks insurance claim forms to make sure that the data provided by policyholders is comprehensive and accurate is known as a claims examiner. While some work in property and casualty claims, the majority are in the health or life insurance industries. For health insurance claims, you may speak with medical experts and refer to standardized rate tables to ascertain whether the expenses of a diagnosis or course of treatment are acceptable. In the case of life insurance claims, you might check the medical background of potential policyholders to see if they’re a good risk or check the manner of death for the heirs of existing policyholders. After that, you choose whether to accept, reject, or submit claims to a claims investigator.

Claims examiners work for both life and health insurance providers as well as property and casualty (P&C) businesses. Job titles could include medical claims examiner, workers’ compensation examiner, property claims adjuster, or bodily injury claims examiner depending on the sector of employment. A claims examiner’s responsibilities include examining claims that have been submitted for payment to make sure that insurance adjusters and claimants have complied with policies, determining the claim amount the business should pay, and negotiating settlements. Examiners of claims typically work late or weekend hours while working full-time. They might also leave the area to evaluate the damage.

 

Claims examiners are employed in a variety of places, such as offices, hospitals, and insurance firms. They normally put in a 40-hour work week, but they would need to put in more time if things are hectic, such as right after a natural disaster. As claims examiners must decide quickly whether to approve or deny claims, the work can be demanding. They also deal with disgruntled clients who may be upset by the choice. To diffuse these circumstances, claims examiners need to possess outstanding customer service abilities. Additionally, they must be able to manage a significant amount of work while maintaining a high standard of accuracy.

 

Claims Examiner Job Description

What is a claims examiner job description? A claims examiner job description is simply a list of duties and responsibilities of a claims examiner in an organization. Below are the claims examiner job description examples you can use to develop your resume or write a claims examiner job description for your employee. Employers can also use it to sieve out job seekers when choosing candidates for interviews.

The duties and responsibilities of a claims examiner include the following:

  • Examine reports thoroughly to make sure the evaluation process was error-free.
  • Verify the reasonableness of rewards.
  • Accept, deny, or refer a claim to an expert.
  • Convene with claimants to resolve differences.
  • Ensure adherence to corporate policies and procedures as well as regulatory norms.
  • Help claims adjusters handle the number of cases by offering help.
  • Consult with experts including attorneys, engineers, architects, and doctors.
  • Assist lawyers and other experts in defending the business against claims.
  • Review insurance applications, approving those that comply with standards while rejecting those that don’t
  • Interview applicants to acquire information about their claims, such as specifics of the circumstances surrounding the accident, the people involved, and how the injury was sustained
  • Investigate an insurance claim to determine whether it is legitimate or fraudulent
  • Examine inning medical reorganizational claim-related paperwork to ascertain responsibility and damages
  • Interpret the provisions of an insurance policy to assess the legitimacy of a claim
  • Gather information regarding accidents and injuries by speaking with witnesses
  • Determine whether an illness or injury qualifies for insurance coverage under a policy
  • Carry out a study to obtain evidence to back up or disprove allegations
  • Create an email to other insurance company staff members with detailed reports on claim findings
  • Attend complete program of corporate training
  • Process claims by existing policy, corporate, and client criteria and approved by the Claims Supervisor and/or Director, depending on their degree of authority, before payment.
  • Utilize numerous internal and external systems to process claims.
  • Work autonomously while collaborating with others.
  • Assess the correctness of professional and/or hospital claims by predetermined dollar levels and complies with and upholds production and quality standards.
  • Review the provider’s contract and/or authorization before deciding how to handle claims
  • Complete all communication, follow-up, and other tasks assigned by the claims supervisor.
  • Process small commercial claims, mobile homes, and dwellings (including condo units).
  • Determine when and if an expert is necessary.
  • Review the system’s job queues, swiftly entering or updating data

 

Qualifications

  • Finance or a closely related field bachelor’s degree is preferable.
  • Good organizational and administrative skills.
  • Excellent focus on detail.
  • Strong interpersonal abilities.
  • Outstanding written and verbal communication.
  • Proficiency in spreadsheets and mathematics.
  • Demonstrated the ability to make decisions.

 

Essential Skills

  • Technical abilities: The capacity to use software, programs, and technology is referred to as technical skills. To study medical records, identify liability, and calculate the amount of compensation a claimant is entitled to, claim examiners may employ computer programs.
  • Communication skills: Effective interaction practice sen practices between employees and other parties require effective communication skills. It may be necessary for you to speak with clients as a claims examiner to update them on the status of their claim or to obtain more details. To discuss settlements, you need to speak with insurance agents.
  • Research abilities: Research abilities include the capacity to locate and analyze data. The information concerning insurance claims that claim examiners gather includes the specifics of the incident, the rules and regulations that apply to the claim, and the pertinent details about the parties involved. To learn more about the policies and practices of the insurance business, claim examiners also use their research abilities.
  • Attention to details: The capacity to detect subtle distinctions and changes in information is known as attention to detail. To ensure they catch any inconsistencies in the information they analyze, claim examiners must pay close attention to every detail. They can use this to confirm the information’s accuracy and determine whether the allegations are justified.
  • Problem-solving abilities: As claims examiners frequently need to discover answers for difficult problems, problem-solving abilities are crucial. Claim examiners can need to come up with solutions for clients who have suffered monetary losses as a result of an insurance company’s mistake. They might also need to figure out how to assist clients who have suffered physical or psychological injury as a result of an insurance company’s mistake.

 

How to Become a Claims Examiner

  • Get a diploma: You must have at least a high school diploma or GED to work as a claims examiner. Even though insurance subjects are rarely offered in high schools, math classes can give students background information that can be applied to claims examinations. You can further prepare for any general office work you could be allocated by taking business classes or office skills courses.
  • Earn a degree: Although there are no formal postsecondary education requirements for claims examiners, earning a certificate or degree may increase your chances of employment. O*Net OnLine data reveals that 67 percent of workers in the category of adjusters, examiners, and investigators have a bachelor’s degree, compared to 11 percent who have an associate’s. 2-year and 4-year institutions offer certificate programs in claims examination and medical claims examination. You learn about the lingo used in the insurance sector, different kinds of claims, and customer service. A year or less is required to finish some programs. Numerous universities offer 4-year bachelor’s degree programs in insurance and risk management that cover a wide range of insurance business ideas and prepare you for a job as an examiner. Different forms of insurance, insurance legislation, and risk management theory are all covered in the courses.
  • Think about doing an internship: The everyday responsibilities of claim examiners and other professionals can be directly experienced through an internship with an insurance company, which also gives you the chance to network and build experience. Occasionally, when you finish school, they can lead to a career. The curriculum of some bachelor’s programs and internships
  • Get Your License If Required: The licensure criteria for examiners vary greatly between states. You might simply need to register in some. In others, you could need to finish a course of study, get a certain grade, or do both. Some people might also anticipate that you obtain continuing education credits, which include enrolling in classes, giving talks, or producing content for insurance journals.
  • Go after a job: The U.S. Bureau of Labor Statistics indicates that insurance carriers, agencies, and brokerages are the most likely places for you to find work. Governmental organizations at the federal and state levels offer a more limited but substantial source of opportunity. Examiner employment in 2020 was projected to be around 333,800, excluding self-employed individuals. It is anticipated to fall to 324,700 over the decade from 2020 to 2030. The necessity to control healthcare expenses and the requirement for examiners to analyze an increasing number of insurance claims from senior patients will be what will determine your career possibilities.

 

Where to Work as a Claims Examiner

  1. Governmental organizations
  2. Insurance companies

 

Claims Examiner Salary Scale

In the USA, the typical claims examiner earns $49,006 annually or $25.13 per hour. Most experienced workers earn up to $75,027 per year, while entry-level occupations start at $36,869 annually.

In the UK as a trainee claims examiner, for instance, the starting pay is between £16,500 and £18,000. Graduate trainees’ starting salaries typically vary from £18,000 to £25,000.

Claim examiners with experience can make between £20,000 and £30,000 annually. Team leader jobs and claims examiners with greater complexity may command higher pay.

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