Insurance Claims Examiner Sample Job Descriptions

Insurance claims examiners are critical to the insurance industry. They are responsible for evaluating and reviewing various insurance claims and applications to ensure the due process was followed during investigations. This allows insurance adjusters’ and claimants’ work to be double-checked before any claims are approved. Insurance claims examiners need to be knowledgeable about various insurance laws to make sure legal compliance is being met and to help claims adjusters when they need it. [Your Company] is on the lookout for an experienced insurance claims examiner. We’re specifically searching for someone with great organizational skills who can pay close attention to the claims they’re looking over. If you are diligent in your work and enjoy working in insurance, we recommend that you apply to our open position as an insurance claims examiner!

Typical duties and responsibilities

• Determine covered medical insurance losses by studying provisions of policy or certificate
• Establish proof of loss by studying medical documentation
• Assemble information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies
• Initiate or investigate questionable claims
• Document medical claims actions by completing forms, reports, logs, and records
• Resolve medical claims by approving or denying documentation, calculate benefits due, initiate a payment, or compose a denial letter
• Ensure legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations
• Maintain quality customer service by following customer service practices
• Respond to customer inquiries

Education and experience

This position requires a high school diploma or equivalent. However, a bachelor’s degree is preferred.

Required skills and qualifications

• Understanding of health insurance administration processes
• Strong attention to detail
• Knowledge of medical terminology
• Excellent interpersonal skills

Preferred qualifications

• 4+ years of claim handling experience and demonstrated proficiency in analyzing and handling claims 
• Excellent written and verbal communication skills

Job summary:

Responsible for the timely and accurate adjudication of all claims for ABC Company products. Reviews and resolves pended and corrected claims. Analyzes claim resubmissions to determine areas for provider education or system re-configuration. Serve as the primary point of contact for claim issues raised by Providers and internal ABC Company departments. Provides feedback on department workflows and identifies opportunities for a redesign. Performs claims testing to ensure that systems are designed efficiently based on the Plan’s benefit structure.

Responsibilities:

• Review, research and finalize provider claims within established regulatory requirements and ABC Company policies
• Analyze provider issues and collaborate with other departments to resolve them. Identifies and documents opportunities for provider education
• Review provider disputes or appeals and provide a detailed analysis of findings
• Conduct claim testing for ABC Company products
• Review claim processing results of Delegated Vendors
• Provides expertise and assistance relative to provider billing and payment guidelines consistent with ABC Company policies and procedures and State or CMS guidelines
• Document all provider contacts, including telephonically, emails, written correspondence
• Troubleshoot and identify the root cause of problems and participate in developing solutions
• Provides follow-up and intervention relating to provider claim inquiries
• Collaborate with internal teams and departments to ensure applications are processed, contracts are executed and all providers are credentialed in a timely manner.
• Participates in standing meetings as necessary, including but not limited to provider relations, contracting, network development, team building, etc.
• Performs other duties and special projects as assigned and directed

Education and experience:

• BA/BS degree in a financial field or equivalent healthcare experience
• 3+ years of claim processing experience, preferably in a Medicaid/Medicare, MLTC environment, Customer Service in a health insurance product environment.
• Use of Microsoft Access or a similar query tool. Proficiency with MS applications, including but not limited to Word, Excel, Outlook, PowerPoint, Project
• Strong telephonic and customer service skills

Knowledge and skills:

• Effective presentation skills
• Excellent verbal and written communication skills
• Must be able to participate in meetings with all levels of management within the organization
• Detail-oriented, excellent follow-up
• Ability to multi-task in a fast-paced environment
• Must be service-oriented, quick learner, and team player
• Appreciation of cultural diversity and sensitivity toward the target population

Review claims of a lower to moderate level and related documentation to determine if the loss is covered and what benefits apply.

Responsibilities

• Key responsibilities which take no less than 10% of overall job time
• Regular, predictable, reliable attendance is an essential function of this position
• Review claims, identify the incident, determine coverage in accordance with the contract, conclude what, if any benefit applies and the amount to be reimbursed
• Responsible for paying or rejecting the claim in accordance with the terms and conditions of the insuring agreement
• Follow up with the customer either by letter, email, or telephone call once the claim has been resolved
• Answer incoming telephone or email inquiries from customers regarding the status of their claim
• Enter determination and relevant notes into PeopleSoft in accordance with guidelines
• Collaborate with other departments as needed to verify or obtain missing information
• Research discrepancies and escalate questionable claims to the Manager
• Send out claim forms to new customers as needed
• May perform other duties as assigned

Minimum qualifications

• High school diploma or equivalent diploma
• Zero (0) to one (1) years of experience in a customer service-related function
• Bilingual preferred; may be required based on business need
• Previous claims experience preferred

Responsibilities

• Handles claims of low to moderate complexity
• Obtains and records first notice of loss
• Determines and advises of all applicable coverage for the loss, including resolving all questions of coverage associated with the claim
• Analyzes applicable state policy and endorsements to determine the appropriate coverage
• Analyzes claim to determine coverage recommendation
• Arranges all emergency services required to protect the property from further harm; accommodate the needs of the insured
• Works with a variety of virtual estimating applications to complete inspections and estimates
• Comes to an agreement regarding the cost of repair with the insured, possibly the Network Repair Program (NRP), or the insured’s contractor
• Settles and pays dwelling, other structural damage, contents, and/or loss of use once the coverage analysis is completed
• Handles all correspondence to ensure the file is regulatory compliant
• Recognizes subrogation potential and completes necessary investigation and referral

Qualifications

• High School diploma or GED required
• 2-5 years of claims experience required with preferred emphasis on homeowner claims
• Ability to effectively handle multiple tasks using various applications
• Analytical, problem-solving, and organizational skills
• Basic mathematics skills
• Strong verbal and written communication skills
• Proficient with computers and the ability to type 30 or more words per minute
• Outstanding interpersonal and customer service abilities
• Ability to acquire and maintain regulatory adjusting licenses in the states where required
• Knowledge of homeowner policies and procedures
• Knowledge of and writing skills in the Xactimate repair estimating system
• Knowledge of home construction