What Does an Insurance Claims Examiner Do?
An insurance claims examiner reviews insurance claims after they’ve been investigated by adjusters to ensure accuracy, completeness, and compliance with policy terms. Their main responsibility is to validate the adjuster’s findings, assess the legitimacy of claims, and authorize appropriate settlement amounts. Claims examiners often handle more complex or high-value cases, working closely with adjusters, legal teams, and senior management to ensure claims are processed fairly and in accordance with regulations.
Claims examiners also monitor for inconsistencies or potential fraud, recommend further investigation when needed, and may participate in training new claims staff. This role is highly detail-oriented and requires strong knowledge of insurance coverage types, documentation standards, and industry regulations. Whether in property, casualty, health, or life insurance, examiners play a vital part in balancing customer support with company risk protection.
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Insurance Claims Examiner Core Responsibilities
- Review completed claim files to ensure proper documentation and accuracy
- Evaluate adjusters’ reports, medical records, repair estimates, and legal documentation
- Interpret insurance policies and determine claim eligibility and settlement terms
- Approve, modify, or deny claims based on policy provisions and findings
- Identify potential fraud, inconsistencies, or need for further investigation
- Ensure claim handling complies with federal and state regulations
- Collaborate with adjusters, underwriters, and legal teams as needed
- Maintain accurate records and update claims management systems
- Prepare detailed reports and recommendations for escalated or disputed cases
- Support internal audits and compliance reviews
Required Skills and Qualifications
Hard skills
- Proficiency with claims management software (e.g., Guidewire, Origami, Duck Creek)
- Strong understanding of insurance policies, coverage types, and claim types
- Ability to analyze documentation such as police reports, medical files, or contractor estimates
- Familiarity with industry regulations (HIPAA, ERISA, state-specific statutes)
- Skilled in drafting formal claim decisions and audit notes
Soft skills
- High attention to detail and accuracy
- Strong analytical and critical thinking skills
- Discretion and ethical judgment
- Clear and professional written communication
- Ability to work independently and meet deadlines
Education
- Associate’s or bachelor’s degree in insurance, business, finance, or related field
Certifications
- Insurance claims certification (e.g., AIC – Associate in Claims) recommended
- State licensing may be required depending on claim type and employer
Preferred Qualifications
- 3+ years of experience in insurance claims, underwriting, or adjusting
- Experience in a specific claims area (health, property, auto, casualty, or disability)
- Background in claims auditing or fraud detection
- Familiarity with ICD-10 codes (for health examiners) or Xactimate reports (for property examiners)
National Average Salary
Insurance claims examiner salaries vary by experience, industry, organization size, and geography. Click below to explore salaries by local market.
The average national salary for an Insurance Claims Examiner is:
$60,485
Sample Job Description Templates for Insurance Claims Examiners
Health Insurance Claims Examiner
Position Overview
The health insurance claims examiner reviews and evaluates medical insurance claims to ensure accuracy, policy compliance, and eligibility. This role validates coding, benefit coverage, and documentation submitted by healthcare providers before approving or denying payment.
Responsibilities
- Review medical claims for completeness, accuracy, and compliance with plan terms
- Verify coverage eligibility and policy limits
- Analyze procedure and diagnosis codes (CPT, ICD-10, HCPCS)
- Identify duplicate billing, overcharges, or non-covered services
- Approve, deny, or pend claims with documented rationale
- Collaborate with providers, policyholders, and internal teams to resolve discrepancies
- Maintain records in claims systems and ensure HIPAA compliance
Requirements
Hard skills
- Knowledge of medical terminology and billing codes (ICD-10, CPT, HCPCS)
- Experience with claims platforms (e.g., Facets, HealthEdge, Epic Tapestry)
- Understanding of Explanation of Benefits (EOB) and coordination of benefits
Soft skills
- Attention to detail and investigative mindset
- Confidentiality and data privacy awareness
- Ability to meet review deadlines under volume pressure
Education
- Associate’s or bachelor’s degree in health administration or related field
Certifications
- Certified Professional Coder (CPC) or AHIMA credentials (recommended)
Preferred Qualifications
- 2+ years in medical claims, billing, or healthcare administration
- Experience with HMO, PPO, or Medicare/Medicaid plans
Property Claims Examiner
Position Overview
The property claims examiner reviews residential or commercial property insurance claims submitted by adjusters. This role ensures damage assessments align with policy coverage, validates estimates, and authorizes or denies payouts based on documentation.
Responsibilities
- Evaluate damage estimates, repair invoices, and adjuster reports
- Confirm coverage based on policy terms and exclusions
- Identify discrepancies in damage appraisals or cause-of-loss findings
- Approve or recommend modifications to settlement proposals
- Maintain claim documentation for audit and regulatory compliance
- Collaborate with adjusters, underwriters, and legal staff on disputed claims
Requirements
Hard skills
- Proficiency with Xactimate, Symbility, or estimating tools
- Knowledge of construction terminology and property insurance policies
- Familiarity with disaster loss types (fire, flood, hail, etc.)
Soft skills
- Analytical thinking and documentation skills
- Judgment in complex or large-loss evaluations
- Ability to work cross-functionally with field and legal teams
Education
- Associate’s or bachelor’s degree in insurance, construction, or related field
Certifications
- Xactimate Level 1 or 2 recommended
- State licensing if required for examiners
Preferred Qualifications
- Background in property adjusting or home inspection
- Experience reviewing catastrophe claims
Auto Claims Examiner
Position Overview
The auto claims examiner reviews vehicle insurance claims to verify liability, validate repair estimates, and authorize payment. This role ensures claims comply with policy guidelines, depreciation rules, and state laws.
Responsibilities
- Review police reports, accident details, repair shop estimates, and adjuster notes
- Verify vehicle coverage, fault determinations, and third-party liability
- Identify inconsistencies or potential fraud
- Approve or revise settlements based on valuation and damage documentation
- Maintain claim records and handle compliance-related documentation
- Support litigation files when claims are disputed
Requirements
Hard skills
- Familiarity with CCC One, Mitchell, or Audatex estimating platforms
- Understanding of bodily injury vs. property damage claims
- Knowledge of policy structures, deductibles, and depreciation
Soft skills
- Problem-solving and logical reasoning
- Clear communication with claimants and service providers
- Discretion when handling sensitive or legal claims
Education
- High school diploma required; associate’s degree preferred
Certifications
- State-specific claims examiner license if required
Preferred Qualifications
- Prior experience in auto adjusting, repair, or collision estimating
- Understanding of liability claims and subrogation
Life Insurance Claims Examiner
Position Overview
The life insurance claims examiner validates death benefit claims, ensuring accuracy of documentation and compliance with policy terms. The examiner verifies beneficiary eligibility, confirms death certificates, and identifies potential fraud or misrepresentation.
Responsibilities
- Review submitted death certificates, policy documents, and beneficiary information
- Verify policy status, coverage limits, and exclusions
- Identify contestable claims or misrepresentations
- Coordinate with legal and underwriting teams on suspicious or large claims
- Approve or deny payment based on policy compliance
- Communicate with beneficiaries and agents professionally and empathetically
Requirements
Hard skills
- Knowledge of life insurance products, beneficiary rules, and policy clauses
- Familiarity with claim documentation and legal notices
- Experience using insurance systems (e.g., VUE, LifePRO, FAST)
Soft skills
- Attention to legal and ethical standards
- High emotional intelligence in sensitive conversations
- Structured and clear decision-making
Education
- Bachelor’s degree in insurance, legal studies, or business
Certifications
- LOMA (e.g., ACS or FLMI) certification recommended
Preferred Qualifications
- Experience with contested or high-value death claims
- Background in estate law or beneficiary services
Disability Claims Examiner
Position Overview
The disability claims examiner evaluates short-term and long-term disability claims to determine eligibility for benefits. This includes reviewing medical records, physician statements, and work restrictions to ensure the claimant qualifies under plan provisions.
Responsibilities
- Assess initial and continuing eligibility for disability benefits
- Review medical documentation and occupational information
- Coordinate with physicians, employers, and vocational experts
- Determine benefit duration and payment amount
- Monitor ongoing claims and request periodic updates
- Document all actions in accordance with regulatory requirements
Requirements
Hard skills
- Knowledge of disability claim procedures and policy types (STD, LTD)
- Familiarity with ICD-10 codes and functional capacity evaluations (FCEs)
- Proficiency with claims platforms (e.g., Matrix, Sedgwick, The Standard)
Soft skills
- Confidentiality and discretion
- Strong judgment in complex medical and occupational cases
- Clear documentation and case communication
Education
- Associate’s or bachelor’s degree in healthcare, insurance, or HR
Certifications
- CEBS or Disability Management Specialist (CDMS) recommended
Preferred Qualifications
- Experience working in ERISA-governed disability plans
- Background in vocational rehabilitation or occupational health