Claims Examiner
A claims examiner reviews insurance claims to determine the extent of the insuring company's liability and settles claims with claimants in accordance with policy terms.
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Sample Job Descriptions for Claims Examiner
Below are the some sample job descriptions for the different experience levels, where you can find the summary of the role, required skills, qualifications, and responsibilities.
Junior (0-2 years of experience)
Summary of the Role
A Claims Examiner is responsible for assessing insurance claims to determine the extend of the insuring company's liability. The role involves reviewing claims, verifying information with policy holders, analyzing claim information, and making decisions on claim settlements. Junior Claims Examiners will work under the guidance of senior staff and will be expected to develop an understanding of claims processing and industry regulations.
Required Skills
- Data analysis
- Effective communication
- Record keeping
- Critical thinking
- Time management
- Basic knowledge of insurance industry
Qualifications
- Bachelor's degree in finance, business administration, or related field.
- Excellent analytical and problem-solving skills.
- Strong communication and interpersonal abilities.
- Attention to detail and the ability to work with complex documents.
- Familiarity with computer and database applications.
- Ability to work in a team and learn from experienced professionals.
Responsibilities
- Review and evaluate insurance claims for accuracy and completeness.
- Interact with policy holders to obtain additional claim information as necessary.
- Analyze claims to determine the level of liability of the company.
- Work closely with senior examiners and learn industry-specific regulations and procedures.
- Ensure compliance with legal requirements and company policies.
- Maintain accurate and up-to-date claims data in the company's database.
Intermediate (2-5 years of experience)
Summary of the Role
As an intermediate Claims Examiner, you will be responsible for reviewing and analyzing insurance claims to determine the extent of the insuring company's liability. In this role, you will ensure that all claims are settled in a timely and fair manner, in accordance with company policies and procedures. The ideal candidate will be adept at managing multiple claims, identifying potentially fraudulent activities, and working collaboratively with claims adjusters and other related departments.
Required Skills
- Strong analytical and critical thinking skills.
- Effective communication and interpersonal skills.
- Proficiency in using claims software and related technology.
- Attention to detail and accuracy in claim review.
- Good organizational and time management skills.
- Adaptability to changing regulations and procedures.
- Ability to work independently and as part of a team.
Qualifications
- Bachelor's degree in insurance, business administration, or a related field.
- 2-5 years of experience working as a claims examiner or in a related role within the insurance industry.
- In-depth understanding of insurance policies, coverage, and regulations.
- Certification as a Certified Claims Professional (CCP) or equivalent is preferable.
- Strong analytical and decision-making skills.
- Excellent verbal and written communication abilities.
- Proficiency in claims management software and MS Office.
Responsibilities
- Examine insurance claims and evaluate their validity and accuracy.
- Determine the appropriate settlement amount based on policy coverage and claim analysis.
- Coordinate with claim adjusters, policyholders, and other relevant parties to resolve claims issues.
- Identify and investigate potential fraudulent claims to protect company resources.
- Ensure compliance with legal requirements, industry regulations, and company policies.
- Maintain accurate records and documentation for each claim reviewed.
- Provide excellent customer service by addressing policyholder queries promptly and professionally.
- Stay up-to-date with the latest industry trends, best practices, and technological advancements.
Senior (5+ years of experience)
Summary of the Role
A Senior Claims Examiner is responsible for the review and analysis of complex claims before determining coverage and liability. This seasoned professional utilizes their extensive industry knowledge to mentor less experienced staff, manage significant caseloads, and coordinate with other departments to resolve claims effectively. Their expertise allows them to handle cases that require detailed investigations and a deep understanding of policy provisions and legal issues.
Required Skills
- Critical thinking and analytical problem-solving.
- Effective communication and interpersonal abilities.
- Mastery of claims handling procedures and best practices.
- Proficient in report writing and documentation.
- Excellent negotiation and conflict resolution.
- Strong leadership and mentoring capabilities.
- Ability to work independently and make sound judgments.
- High level of organizational and multitasking skills.
- Competency in utilizing industry-specific software and technology.
- Knowledgeable in regulatory compliance and industry standards.
Qualifications
- Bachelor's degree in insurance, business administration, law, or related field.
- Minimum of 5 years of experience in claims examination or claims handling within the insurance industry.
- Possession of professional certifications such as CPCU, AIC, SCLA, or similar is preferred.
- Demonstrated experience with complex claim investigations and settlement negotiations.
- In-depth understanding of insurance policy language and legal terminology.
- Strong analytical skills and attention to detail.
- Proven managerial or supervisory experience is a plus.
- Excellent oral and written communication skills.
- Proficiency with claims management software and Microsoft Office Suite.
- Familiarity with medical terminology and concepts is beneficial.
Responsibilities
- Conduct thorough and detailed investigations of complex insurance claims.
- Determine claim coverage by reviewing policy agreements and examining the evidence.
- Interpret policy provisions and analyze involved legal issues to assess the company's liability.
- Coordinate with legal counsel, medical experts, and other professionals as necessary.
- Provide guidance and mentorship to junior claims examiners and other staff.
- Negotiate settlements with policyholders, attorneys, or other claimants.
- Ensure compliance with regulatory requirements and internal policies.
- Prepare detailed claim reports and recommendations for management.
- Manage a significant volume of claims efficiently and prioritize tasks effectively.
- Stay current with industry trends, legal developments, and policy changes.
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