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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
Insurance company claims examiners usually supervise claims adjusters. They make sure that payments and settlements have been made in accordance with company practices and procedures and that the adjuster's repair estimates are accurate.
Claims examiners report overpayments, underpayments, a ...
nd irregularities. They confer with attorneys, medical personnel, and experts on claims that go to court. They also help guard against insurance fraud, whether it involves false medical claims, faked documents, or even murder-for-profit.
That's why, in addition to an ability to deal with the complexities of insurance regulations and claim procedures, it is important to be able to tell if a given claim makes sense. When the details don't add up, it can be very satisfying to apply your knowledge and skills to uncover the suspected fraud and see to it that the perpetrators are brought to justice.
Review settled insurance claims to determine that payments and settlements have been made in accordance with company practices and procedures. Report overpayments, underpayments, and other irregularities. Confer with legal counsel on claims requiring litigation.
Critical decision making
Level of responsibilities
Job challenge and pressure to meet deadlines
Dealing and handling conflict
Competition for this position
Communication with others
Work closely with team members, clients etc.
Comfort of the work setting
Exposure to extreme environmental conditions
Exposure to job hazards
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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.
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.
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.
Adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies.
Investigate, evaluate and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.
Pay and process claims within designated authority level.
Observing, receiving, and otherwise obtaining information from all relevant sources.
Resolving Conflicts and Negotiating with Others
Handling complaints, settling disputes, and resolving grievances and conflicts, or otherwise negotiating with others.
Interacting With Computers
Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
Communicating with Supervisors, Peers, or Subordinates
Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
Identifying Objects, Actions, and Events
Identifying information by categorizing, estimating, recognizing differences or similarities, and detecting changes in circumstances or events.
Evaluating Information to Determine Compliance with Standards
Using relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
Making Decisions and Solving Problems
Analyzing information and evaluating results to choose the best solution and solve problems.
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.
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.
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.
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.
Computers and Electronics
Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
Knowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications.
Building and Construction
Knowledge of materials, methods, and the tools involved in the construction or repair of houses, buildings, or other structures such as highways and roads.
The ability to read and understand information and ideas presented in writing.
The ability to listen to and understand information and ideas presented through spoken words and sentences.
The ability to apply general rules to specific problems to produce answers that make sense.
The ability to communicate information and ideas in speaking so others will understand.
The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
The ability to communicate information and ideas in writing so others will understand.
The ability to identify and understand the speech of another person.
The ability to speak clearly so others can understand you.
Understanding written sentences and paragraphs in work related documents.
Communicating effectively in writing as appropriate for the needs of the audience.
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
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.
Talking to others to convey information effectively.
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.
Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.