Insurance Claims ExaminerJob Description, Salary, Career Path, and Trends

Insurance claim examiners are essential to the insurance industry as they make sure all insurance claims are properly using due process during investigations. 

Insurance claims examiners are often found working with health insurance claims and documentation. They are responsible for working with a patient’s health insurance to check if their policy covers their health expenses. Insurance claims examiners need to have a deep understanding of insurance laws to ensure legal compliance is being met when claim adjusters evaluate the insurance claims.

This job position involves a variety of duties and responsibilities. It is important for insurance claims examiners to have good customer service skills to be compassionate when dealing with customers that were denied claims. There are opportunities for promotion for hard-working insurance calms examiners like becoming a life insurance actuary or claims director.

Sample job description #1

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 redesign. Performs claims testing to ensure that systems are designed efficiently based on the Plan’s benefit structure.

Primary 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. 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
  • Trouble shoot and identify 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:

Required

  • 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 health insurance product environment.
  • Use of Microsoft Access or similar query tool. Proficiency with MS applications, including but not limited to Word, Excel, Outlook, Power Point, 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, team player
  • Appreciation of cultural diversity and sensitivity toward target population

Sample job description #2

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

Job functions

  • 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 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 experience in a customer service related function
  • Bilingual preferred; may be required based on business need
  • Previous claims experience preferred

Sample job description #3

Essential 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’s policy and endorsements to determine appropriate coverage
  • Analyzes claim to determine coverage recommendation
  • Arranges all emergency services required to protect the property from further harm; accommodates the needs of the insured
  • Works with a variety of virtual estimating applications to complete inspections and estimates
  • Comes to an agreement regarding 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

What would make us excited about you

  • 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 license in the states where required
  • Knowledge of homeowner policies and procedures
  • Knowledge of and writing skills in Xactimate repair estimating system
  • Knowledge of home construction

Average salary and compensation

The average salary for an insurance claims examiner is $58,250 in the United States. Position salary will vary based on experience, education, company size, industry, and market.

LocationSalary LowSalary High
Phoenix, Arizona$57,950$78,400
Los Angeles, California$65,350$88,400
Denver, Colorado$54,450$73,700
Washington, DC$66,350$89,750
Miami, Florida$54,200$73,350
Orlando, Florida$50,000$67,650
Tampa, Florida$50,500$68,350
Atlanta, Georgia$53,000$71,700
Chicago, Illinois$60,900$82,400
Boston, Massachusetts$65,850$89,100
Minneapolis-St. Paul, Minnesota$52,500$71,000
New York City, New York$69,300$93,800
Philadelphia, Pennsylvania$56,450$76,350
Dallas, Texas$54,950$74,350
Houston, Texas$54,450$73,700
Seattle, Washington$63,400$85,750
National Average$49,500$67,000

Sample interview questions

  • Tell us about yourself and why you’re interested in this position.
  • How do you process claims?
  • How well do you manage your time? How do you stay organized?
  • Tell us how your last job prepared you for this position as an insurance claims examiner.
  • What qualities do you possess that will help you succeed as an insurance claims examiner at our company?
  • How would you deal with a hostile customer who is unhappy with your examination?
  • What do you believe is your role in assisting insurance adjusters and claimants? 
  • What would you do if there was important information missing during your examination?
  • How would you handle a situation involving a disagreement with the insurance adjuster regarding the amount paid to the claimant?
  • How do you ensure consistency in evaluating damages?
  • What would you do to prepare for an interview with a legal representative?
  • How do you ensure compliance with due process in investigations?
  • Describe your negotiation skills.
  • How would you make sure you wouldn’t miss any important information that could affect the amount given to the claimant?
  • How do you manage stress?
  • If a customer got into a car accident and you confirmed they will need a repair on part of the car, but they want the whole part to be replaced, how would you handle the situation?
  • Are you willing to visit other sites outside of business hours?

Insurance Claims Examiner Jobs in Ashburn

    Loading RSS Feed

Need help hiring an Insurance Claims Examiner?

We match top professionals with great employers across the country. Your next career move or star employee is just around the corner. Review our career content and advice, browse our latest job openings, or email us your resume. We look forward to connecting with you soon!

Browse A-Z Job Descriptions