Claims Representative Job Description

Claims Representative Job Description, Skills, and Salary

Get to know about the duties, responsibilities, qualifications, and skills requirements of a claims representative. You can use our job description template in this article to produce your own. We also provide you with information about the salary you can earn as a claims representative.

 

Who is a Claims Representative?

A claims representative is an agent who investigates and settles claims for insurance companies. The claims representative acts as a liaison between customers and insurance companies, evaluating the facts surrounding claims and determining whether or not the loss is covered or should be compensated.

They are in charge of determining whether the loss is covered and how much compensation should be paid. They conduct extensive investigations to ensure that an insurance claim is not fraudulent, and they may be required to contact relevant third parties such as a doctor or an employer, or consult with a police report. Claims representatives ultimately negotiate insurance settlements, authorize payments, and keep records.

 

Claims Representative Job Description

Below are the claims representative job description examples you can use to develop your resume or write a job description for your employee. Employers can also use it to sieve out job seekers when choosing candidates for interviews.

The claims representative is typically responsible for the following tasks.

  • Double-check the accuracy and completeness of new claims before sending them to the underwriter for approval.
  • Explain insurance policies to customers and assist them in selecting the best coverage for their needs.
  • Contact customers to inform them of claim status updates, request additional information about a claim if necessary, and answer any questions they may have about their claim.
  • Examine documentation provided by medical providers or service providers to ensure that services were rendered and charges were reasonable.
  • Process monthly claim checks and mail them to policyholders.
  • Resolve customer complaints by explaining coverage policies and procedures to them and collaborating with them to find solutions.
  • Communicate with insurance companies on behalf of customers who have pending claims, including the submission of paperwork to support claims and the request for payment from insurance companies.
  • Prepare claims activity summaries for internal use or submission to insurance regulators.
  • Negotiate with insurance companies or agents on behalf of policyholders when there are disagreements about claim determinations or payment amounts.
  • Participate in disaster claims contact initiatives to improve customer service.
  • Assist the training department in developing CSR training to set expectations.
  • Contact customers and associates via phone, mobile app, click-to-chat, and internet reporting.
  • Input, track, and investigate member appeal requests following company and CMS policies and procedures.
  • Create custom templates and guide sheets for new trainees in the CSR Internet division to ensure consistency and increase department efficiency.
  • Use proper SIU reporting procedures when conducting extensive investigations.
  • Communicate with customers and associates via phone and internet reporting.
  • Recognize for building relationships with SIU and lowering costs while ensuring proper payment.
  • Analyze national disaster claim and phone call statistics to create a new staffing and scheduling model for a national centralized disaster operation center.
  • Complete loss inspection in the field, including accurate scope of damages, photographic evidence collection, and written estimates using Xactimate estimating software.
  • Establish close coordination with various stakeholders such as public adjusters and local contractors to ensure a faster settlement during the settlement process.

 

Qualifications

Qualifications for becoming a claims representative include the following:

Education: Claims representatives are typically required to have a bachelor’s degree or higher. Business, accounting, and finance are some of the most common majors for claims representatives. These majors equip claims representatives with the knowledge and skills they need to assess and manage claims effectively.

Experience and training: When starting a new job, most claims representatives will receive on-the-job training. This training will assist the claims representative in learning the company’s specific procedures and software. Depending on the complexity of the job, training could last a few weeks or months.

Licenses and certifications: Certifications enable you to demonstrate your abilities and qualifications to current and prospective employers. Certifications allow claims representatives to gain more theoretical knowledge of their responsibilities, put their professional skills to the test, and advance their careers.

 

Essential Skills

To be successful on the job, claims representatives must possess the following abilities:

  1. Excellent communication skills: Emails, letters, and phone calls are used by claims representatives. That means they interact with a large number of people daily, including insurance companies, policyholders, and other related parties, via various communication channels. Being a claims representative requires the ability to effectively communicate vital details to a variety of people, consistently. It ensures that every policyholder receives adequate claim information. It also entails knowing how to effectively communicate verbally and in writing.

Customer service abilities: Claims representatives typically collaborate with both the insurance company and the insured. They help potential customers by answering their questions, requesting additional information, and resolving issues. Excellent customer service representatives help to build strong relationships and increase customer loyalty. They collaborate with both parties to ensure that investigations and compensation are completed on time.

  1. Time management abilities: A claims representative’s daily tasks include making phone calls, scheduling meetings, visiting the site for investigation, preparing paperwork, gathering information, verifying facts, and sharing payment estimates for each claim. Consider hiring a team or using management tools to help you perform your duties as an independent representative. Excellent time management skills enable representatives to complete all tasks on time while providing clients with timely updates.
  2. Analytical abilities: As a claims representative, you must sort through a large amount of information and documents to interpret data. Analytical abilities enable you to double-check and re-check minor details to ensure that important information is not overlooked. Detail-oriented representatives can help share accurate information with relevant parties by fact-checking, interpreting, and analyzing data.
  3. IT Proficiency skills: Claims representatives rely on a variety of computer programs to carry out their responsibilities. Computers are used by insurance companies to compute claim estimates and other related data. Computers make it easier for claims representatives to handle multiple projects at once, increasing efficiency.
  4. Excellent problem-solving abilities: Problem-solving abilities enable you to locate the source of a problem and propose a solution. As a claims representative, you may be responsible for resolving customer concerns and ensuring that the outcome of their claim is satisfactory. This may entail determining the root cause of the problem and proposing a solution that meets the needs of both the customer and the insurance company.
  5. Excellent organizational abilities: Because claims representatives frequently have multiple tasks to complete in a short period of time, the organization is a critical skill. This includes maintaining databases, keeping track of paperwork, and filing claims. Organizing your workspace and time can help you complete tasks more efficiently and effectively.
  6. Product knowledge: Claim representatives should be well-versed in the products and services provided by their company. This can assist them in answering customer questions and identifying potential risks. It’s also critical to understand the company’s policies and procedures so you can process claims correctly.
  7. Fraud Detection Skills: The ability to detect fraud is the ability to detect when a customer is lying or exaggerating their claims. This skill is used by claims representatives to ensure that they are paying customers what they are owed and not overpaying them. This also helps you save money by detecting fraudulent activity. Training, mentorship, and field experience can help you learn how to detect fraud.
  8. Understanding of Subrogation: Subrogation is the process by which an insurance company seeks reimbursement from another party for a loss. For example, if you represent a client who was at fault in a car accident, your employer may seek compensation from the other driver’s insurance company. Negotiation skills are required to ensure that your employer receives fair compensation.
  9. Detail Orientation: The ability to notice and remember minor details is referred to as “detail orientation.” As a claims representative, you may be required to review documents containing detailed information about a person’s health history or accident details. You can process these files more accurately and efficiently if you pay close attention to detail. It also ensures that you provide accurate information to customers regarding their claims.
  10. Competence in Litigation Management: A claims representative must be able to manage litigation, which is the legal process of resolving a dispute. Understanding how to file and track cases in court, as well as how to prepare trial evidence, are all part of this. It also entails knowing how to negotiate with attorneys on your company’s behalf and being familiar with any applicable laws.
  11. Negotiation skills: The ability to reach an agreement with another party is referred to as negotiation. As a claims representative, you may be required to negotiate with clients and insurance companies on their behalf. For example, if a client files a claim for natural disaster damage, you may collaborate with them to determine how much money they should receive from their insurance company. You can use your negotiation skills to help you reach an agreement that is acceptable to both parties.
  12. Investigative abilities: Claims representatives need investigation skills to gather the information needed to process a claim. To determine whether a company should pay out on a claim, you may need to investigate an accident scene, interview witnesses, and examine medical records. Your investigative abilities can also assist you in locating evidence that supports or refutes a claim.

 

How to Become a Claims Representative

To begin your career as a claims representative, follow these steps.

  1. Finish your educational requirements: The education requirements for this position vary depending on the field of insurance and the location where you work. A high school diploma and related coursework are required for a claims representative. While it is not required, having a bachelor’s degree will set you apart from other candidates. It also provides you with skills that you can apply in your future career.
  2. Figure out what kind of claims representative you want to be: The type of claims representative you choose determines the next steps in your career, such as additional training. It’s critical to understand that having excellent communication and detail-oriented skills can help you succeed in any career path.

Begin by researching and networking with insurance agencies in your area to find leads for the most common types of claims representative positions before deciding on the type of representative you want to be. You can also look into the most common insurance companies and their projected growth rate in the coming years. You can then choose to work as one of the following types of claims representatives:

    • Internal claims representative: An inside staff claims representative is an employee who handles claims via letters or phone calls from the insurer’s office. These representatives handle claims that are either covered or not covered and do not investigate the claim’s validity or circumstances. After obtaining permission from the claimant, the insured, or any other witness involved, they can use recording devices to obtain statements about the damage or loss from them.
    • Outside staff claims representative: Outside claims representatives, also known as field claims representatives, assist insurance companies with claims that necessitate on-site inspection, analysis, and investigation. They spend the majority of their time interviewing witnesses, analyzing the scene, and determining the extent of the damage. They also schedule meetings with the insured, lawyers, and other parties who may be involved.
    • Independent adjusters: An independent adjuster represents insurance companies and other private organizations and provides their services to them. Insurance companies that do not employ adjusters rely on independent adjusters to provide these services. As an independent adjuster, you can work for yourself or on a contract basis.
    • Public adjusters: When a policyholder or other claimant files an insurance claim, a public adjuster represents them. In complex cases, the insured may hire a public adjuster to assist them in obtaining fair compensation. On behalf of the insured, public adjusters can negotiate payments with insurance company representatives.
    • Agents: Some insurance companies have a separate office, department, or personnel dedicated to handling claims. Depending on the nature of the claim, an insurance agent with draft authority can settle it. When the agent has finished drafting the claim settlement, the agent in charge can send it to the appropriate department for approval.
  1. Pass the insurance licensing exam: To become a claims representative in your state, you may need to take a course, complete it, and pass a licensing exam. Check your state’s requirements, fill out the necessary paperwork, and enroll in an online course to prepare for any required exams.

Some states require insurance representatives to pass a state exam specific to their insurance specialty. In some states, all independent and public claims representatives must first obtain licenses in their home state before applying for licenses to work in other states. If you live in a state where a license is not required, you can begin representing businesses without taking the licensing exam. Most claims representatives work out of state, so obtaining the Designated Home State (DHS) license is required before working in other states. The license allows you to work in another state that requires a DHS license.

  1. Keep your license current: States that require a license also require continuing education credits for license renewal. Continuing education credits can be obtained by taking live or online courses. Some insurance companies also provide training classes to assist you in obtaining continuing education credits. You can find out what your state requires and how you can meet those requirements.

 

Where to Work as a Claims Representative

Claims representatives typically work in an office setting, though travel to meet with clients or attend conferences may be required. They usually work a standard 40-hour week, but overtime may be required to meet deadlines or handle a high volume of claims. Because claims representatives frequently deal with angry or upset customers, the job can be stressful. They must also be able to manage a large amount of work and make quick decisions.

 

Claims Representative Salary Scale

In the United States, the average claim representative salary is $62,959 per year or $32.29 per hour. Entry-level salaries begin at $50,350 per year, with most experienced workers earning up to $79,140 per year.

The average claim representative gross salary in the United Kingdom is £32,887, or £16 per hour.

The average gross salary for a claims representative in Canada is $78,518 per year or $38 per hour.

In Ireland, the average gross salary for a claims representative is €53,615, or €26 per hour.

In Australia, the average gross salary for a claims representative is $95,372, or $46 per hour.

In Germany, the average gross salary for a claims representative is 56.911 euros or an hourly rate of 27 euros.

A claims representative in Nigeria typically earns around 131,000 Naira per month.

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