What Does an Insurance Claims Examiner Do?
Claim examiners evaluate insurance claims to determine whether they are valid and how much compensation should be paid to the policyholder. In addition to reviewing policy coverage, damages, and supporting documentation provided by the policyholder, they are responsible for reviewing all aspects of the claim. As part of the claims process, insurance claim examiners also communicate with policyholders, adjusters, lawyers, and medical professionals.
Besides conducting investigations, they may also review police reports and medical records to assess damage and loss. Using their knowledge of insurance policies and industry regulations, as well as their investigative skills, they evaluate claims and make sure policyholders receive the compensation they are entitled to.
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National Average Salary
Insurance claims examiner salaries vary by experience, industry, organization size, and geography. To explore salary ranges by local market, please visit our sister site zengig.com.
The average U.S. salary for an Insurance Claims Examiner is:
Insurance Claims Examiner Job Descriptions
It’s important to include the right content in your job description when hiring an insurance claims examiner. The following examples can serve as templates for attracting the best available talent for your team.
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
- 4+ years of claim handling experience and demonstrated proficiency in analyzing and handling claims
- Excellent written and verbal communication skills
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.
- 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.
- 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
- 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
- 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
- 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
Candidate Certifications to Look For
- Associate in General Insurance (AINS). Earning the AINS is the perfect first step into becoming an insurance claims examiner. The course teaches the basic principles of insurance to help candidates excel in their insurance roles. This includes insurance policies and regulations, life insurance planning, homeowners property coverage, insurer financial performance, and more. Earning the Associate in General Insurance will help its candidates achieve their professional goals while attracting more potential employers by showing their willingness to go the extra mile to learn more!
- Certified Insurance Examiner (CIE). Insurance professionals are awarded the CIE if they’ve been trained in a primary field of insurance and have met the proper membership and employment requirements. Candidates must successfully earn and become an Accredited Insurance Examiner, be an IRES member, and have three years of related work experience. Since many employers don’t require a Bachelor’s degree to become an insurance claims examiner, it is extremely valuable to earn certifications like the CIE to demonstrate a candidate’s expertise in the area.
How to Hire an Insurance Claims Examiner
There are a number of initial considerations when hiring an insurance claims examiner:
- Recruiting: Do you have the internal resources and tools to source and recruit for this role successfully?
- Complexity: Does your project require a senior professional, or is a mid- or junior-level inspector sufficient?
- Duration: Is this a one-time project or a permanent requirement?
- Management: Do you have the time and expertise to direct the work effort effectively?
- Urgency: How time-sensitive is this need? What happens if it remains unfilled?
- Headcount: Do you have room on your team for a new W2 employee, or should you consider alternate options?
Answering these questions will help determine the best course of action for your current hiring need. Fortunately, various great options exist for every scenario, no matter how unique. We recommend the following options when hiring an insurance claims examiner:
1. Use 4 Corner Resources (or another professional recruiting firm)
The heavy lifting is done for you when working with a top-tier staffing company like 4 Corner Resources. We source, screen, recruit, and deliver only the most qualified candidate(s), saving you significant time and effort throughout the hiring process while you remain focused on your core business. Understanding your needs and ensuring the right candidate for the position is the key to our success.
This is the best route to take when:
- You need to fill the position quickly
- You want access to a vast talent pool of high-quality, prescreened candidates
- Your position is suited for temporary hiring services, contract staffing, or contract-to-hire recruiting, and you intend to direct the work activity.
- You are hiring an employee as a direct placement but aren’t able to recruit effectively or efficiently with your internal staff.
- You aren’t familiar with current salary rates, market trends, and available skill sets
2. Advertise your opening on a top job board
Your best option may be to advertise your opening on a proven job board. There are many widely used job sites out there that draw visits from qualified candidates. If you have someone internally who can dedicate the time and energy to sort through applications and screen individuals effectively, this can be a great choice.
We recommend using a job board when:
- Your internal recruiting team has the knowledge and experience to assess candidate qualifications
- You are hiring a direct employee and have time to manage the entire recruiting effort
- You have a process for receiving, screening, and tracking all resumes and applications
- You are prepared to respond to all applicants
We recommend using CareerBuilder when hiring an insurance claims examiner:
CareerBuilder has been a trusted source for hiring since 1995. Reach 80+ million unique, diverse U.S. job seekers annually by posting your jobs through their talent acquisition channels. Through CareerBuilder, you can engage candidates and drive them into your sourcing pipeline. We recommend using CareerBuilder for hiring when you have the internal resources and processes to review, screen, and reply to all applicants.
3. Leverage your internal resources
You can utilize your own website, social media, and employees to assist in your search for top candidates.
A company website posting should be the first step in notifying prospective candidates that you are hiring. Social media can also be a powerful tool for spreading the word about your new opening. As far as exposure is concerned, this option can be as good as some job boards when you have a large enough following across various platforms, like LinkedIn, Instagram, Facebook, TikTok, and Twitter.
Current employees are every organization’s greatest asset. Encourage your internal team to promote job openings to their network by offering cash and other incentives.
We recommend these options when:
- Your brand has great name recognition
- You can consistently monitor and respond to candidate activity through your website and social media accounts
- You have a process in place to quickly and broadly communicate job openings and requirements
- You have an effective employee referral program in place
If you aren’t sure which path is best, schedule a discovery call today with our seasoned recruiting professionals. The 4 Corner team is on standby to help you find the best option for your unique hiring need.
Sample Interview Questions
- How do you process claims?
- How well do you manage your workload when working multiple claims?
- Tell us how your last job prepared you for a position as a 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?
- 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?