Insurance Claims Examiner

Typical Duties and Responsibilities 

• Determines covered medical insurance losses by studying provisions of policy or certificate. 
• Establishes proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims. 
• Documents medical claims actions by completing forms, reports, logs, and records. 
• Resolves medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter. 
• Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations. 
• Maintains quality customer services by following customer service practices; responding to customer inquiries. 

Common Skills and Proficiencies 

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

Frequently Required Credentials and Education 

• GED or high school diploma (Bachelor’s degree preferred)