Claims Examiners, Property and Casualty Insurance

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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

ABOUT CLAIMS EXAMINER, PROPERTY OR CASUALTY INSURANCE CAREERS

VIDEO TRANSCRIPT Expand
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.
SNAPSHOT Expand
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.
Leadership
HIGH
Critical decision making
HIGH
Level of responsibilities
LOW
Job challenge and pressure to meet deadlines
HIGH
Dealing and handling conflict
HIGH
Competition for this position
MED
Communication with others
HIGH
Work closely with team members, clients etc.
HIGH
Comfort of the work setting
HIGH
Exposure to extreme environmental conditions
LOW
Exposure to job hazards
LOW
Physical demands
LOW
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DAILY TASKS Expand
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.
MAIN ACTIVITIES Expand
Getting Information 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.
Processing Information Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
AREAS OF KNOWLEDGE Expand
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.
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.
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.
Computers and Electronics Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
Mathematics 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.
KEY ABILITIES Expand
Written Comprehension The ability to read and understand information and ideas presented in writing.
Oral Comprehension The ability to listen to and understand information and ideas presented through spoken words and sentences.
Deductive Reasoning The ability to apply general rules to specific problems to produce answers that make sense.
Oral Expression The ability to communicate information and ideas in speaking so others will understand.
Problem Sensitivity 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.
Written Expression The ability to communicate information and ideas in writing so others will understand.
Speech Recognition The ability to identify and understand the speech of another person.
Speech Clarity The ability to speak clearly so others can understand you.
TOP SKILLS Expand
Reading Comprehension Understanding written sentences and paragraphs in work related documents.
Writing Communicating effectively in writing as appropriate for the needs of the audience.
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.
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.
Monitoring Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
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