Claims Adjusters, Examiners, and Investigators

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Also known as:
Claims Analyst, Fire Claims Adjuster, Health Claims Examiner, Health Insurance Adjuster, Independent Insurance Adjuster, Medical Claims Analyst, Medical Claims Examiner, Property and Casualty Insurance Claims Examiner, Property Damage Claims Adjustor, Reinsurance Claims Analyst

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SNAPSHOT

Review settled claims to determine that payments and settlements are made in accordance with company practices and procedures. Confer with legal counsel on claims requiring litigation. May also settle insurance claims.

Daily tasks

Collect evidence to support contested claims in court.

Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.

Present cases and participate in their discussion at claim committee meetings.

Contact or interview claimants, doctors, medical specialists, or employers to get additional information.

Refer questionable claims to investigator or claims adjuster for investigation or settlement.

Confer with legal counsel on claims requiring litigation.

Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.

Interview or correspond with agents and claimants to correct errors or omissions and to investigate questionable claims.

Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.

Resolve complex, severe exposure claims, using high service oriented file handling.

Review police reports, medical treatment records, medical bills, or physical property damage to determine the extent of liability.

MAIN ACTIVITIES
Interacting With Computers Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
Getting Information Observing, receiving, and otherwise obtaining information from all relevant sources.
Making Decisions and Solving Problems Analyzing information and evaluating results to choose the best solution and solve problems.
Communicating with Supervisors, Peers, or Subordinates Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
Resolving Conflicts and Negotiating with Others Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.
Identifying Objects, Actions, and Events Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
Documenting/Recording Information Entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form.
Processing Information Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
AREAS OF KNOWLEDGE
Customer and Personal Service Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
English Language Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
Law and Government Knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the democratic political process.
Clerical Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology.
Mathematics Knowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications.
Administration and Management Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.
Computers and Electronics Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
Psychology Knowledge of human behavior and performance; individual differences in ability, personality, and interests; learning and motivation; psychological research methods; and the assessment and treatment of behavioral and affective disorders.
TOP SKILLS
Reading Comprehension Understanding written sentences and paragraphs in work related documents.
Critical Thinking Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
Active Listening Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
Speaking Talking to others to convey information effectively.
Writing Communicating effectively in writing as appropriate for the needs of the audience.
Negotiation Bringing others together and trying to reconcile differences.
Judgment and Decision Making Considering the relative costs and benefits of potential actions to choose the most appropriate one.
Active Learning Understanding the implications of new information for both current and future problem-solving and decision-making.