Insurance Claims Examiner

Job Description

If you have an interest in helping others get the health care to which they’re entitled, and you have an eye for details, a job as an Insurance Claims Examiner may be a good fit for you. An Insurance Claims Examiner looks at health insurance claims and documentation and checks it against a patient’s health insurance policy to see whether the policy covers those health services. Also, an Insurance Claims Examiner must also work with patients and health care providers to seek the correct documentation and answer patient questions.

Both verbal and written communication skills are essential for this role. Insurance Claims Examiners will not only have to speak with health care facilities and providers but also to patients and co-workers. They will have to compose denial letters if they determine the patient’s policy does not cover a particular service.

An Insurance Claims Examiner must possess analytical skills to interpret the terms of a policy, which can often be complicated, and determine coverage. Customer service skills, especially when it comes to dealing with customer questions regarding denied claims, are also crucial for this position.

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 Background

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

Skills and Competencies

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

Compensation

According to Payscale the median annual salary of an Insurance Claims Examiner with

1 Year of Experience:

  • Orlando, Florida: $51,000
  • Tampa, Florida: $45,000
  • Jacksonville, Florida: $45,000
  • Miami, Florida: $44,000
  • Atlanta, Georgia: $44,000
  • Chicago, Illinois: $44,000
  • Houston, Texas: $45,000
  • Los Angeles, California: $50,000
  • New York City, New York: $49,000
  • Seattle, Washington: $51,000
  • Overall: $48,000

5 Years of Experience:

  • Orlando, Florida: $64,000
  • Tampa, Florida: $57,000
  • Jacksonville, Florida: $55,000
  • Miami, Florida: $50,000
  • Atlanta, Georgia: $51,000
  • Chicago, Illinois: $60,000
  • Houston, Texas: $59,000
  • Los Angeles, California: $61,000
  • New York City, New York: $66,000
  • Seattle, Washington: $60,000
  • Overall: $59,000

Similar Job Titles

  • Medical Claims Examiner
  • Medical Claims Specialist
  • Health Claims Examiner
  • Health Claims Specialist
  • Claims Processor
  • Claims Analyst
  • Claims Supervisor

Career Path

Insurance Claims Examiners must have at least a high school diploma or GED to be hired. Some companies prefer candidates to have a bachelor’s degree or some previous work experience in the insurance or health care fields. After being hired, Insurance Claims Examiners will usually work on smaller, routine claims under the supervision of a more experienced examiner.

Learning company policies and guidelines, as well as federal and state insurance regulations, is vital for any Insurance Claims Examiner. They must also become acquainted with customary costs of typical medical services as well as their company’s customer service policies. Insurance Claims Examiners can moreover pursue professional certifications such as Associate, Life and Health Claims (ALHC) or Fellow, Life and Health Claims (FLHC) from the International Claim Association to further their careers.

Position Trends

The call for more pricing transparency by health insurance companies is an important trend industry analysts are watching in the coming years. The scrutiny could likely lead to more government regulations on the health insurance industry, which means Insurance Claims Examiners will need to stay abreast of regulatory changes and how that could affect patient coverage.

Another trend in the health insurance industry is the use of predictive analytics. Insurance companies are using big data to help high-risk customers be more proactive about their health to mitigate insurance losses later. That could lead to an influx of more health insurance claims as patients seek out preventive treatments earlier and more often, rather than wait until a significant health issue arises to seek care.

Job Outlook

According to the U.S. Bureau of Labor Statistics, the claims adjusters, appraisers, examiners, and investigators field is expected to shrink by four percent from 2018 through 2028.

Typical Work Hours

Many Insurance Claims Examiners work 9 a.m. to 5 p.m. Monday through Friday in an office setting. However, some who work in companies that assist customers 24 hours a day could work other shifts.

Where You Can Find Jobs

  • 4 Corner Resources
  • Career Builder
  • Glassdoor
  • Indeed
  • LinkedIn
  • Monster 
  • Explore Health Careers

Are You Interested in Becoming an Insurance Claims Examiner?

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