How to Be Claims Examiner - Job Description, Skills, and Interview Questions

The role of a Claims Examiner is to review and analyze insurance claims to ensure they meet the policy requirements and to determine whether they should be approved or denied. In order to do this, they must have a deep understanding of insurance policies and claim processing protocols. As a result, their decisions have a large impact on the overall success of an insurance company, as incorrect decisions can lead to financial losses for the insurer.

It is also important for Claims Examiners to stay up-to-date on industry trends and technological advances, as this will enable them to process claims efficiently and accurately. Furthermore, they must have excellent communication skills in order to negotiate with claimants effectively and resolve disputes quickly.

Steps How to Become

1. Earn a Bachelor's Degree. Claims examiners typically need to have a bachelor's degree in a field such as business, finance, or accounting. This can help prepare them for the job of evaluating and processing insurance claims.
2. Obtain Professional Experience. Many insurance companies prefer claims examiners who have previous experience in the insurance industry. Working as a customer service representative or completing an internship in the insurance industry can help an individual gain the experience needed to become a claims examiner.
3. Complete an On-the-Job Training Program. Most insurance companies offer an on-the-job training program for claims examiners. This can include classroom instruction as well as hands-on training in a real-world setting.
4. Take an Exam. In some states, claims examiners must pass an exam in order to become licensed. This is typically administered by the state's Department of Insurance.
5. Obtain Certification. Some states require claims examiners to be certified. This typically requires passing an exam and completing continuing education courses.

Cause: In order to become an effective and capable Claims Examiner, one must possess a keen eye for detail and an aptitude for understanding paperwork and documentation. Effect: This allows them to analyze claims and accurately identify any discrepancies and inaccuracies, enabling them to make sound judgments when assessing the validity of a claim. Additionally, the ability to effectively communicate with claimants and other stakeholders is essential in order to ensure that all parties are kept updated and informed throughout the claims process. Furthermore, the capacity to remain organized and manage multiple tasks in a timely manner is vital in order to ensure that deadlines are met and that the claims process runs smoothly.

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Job Description

1. Review medical, legal, and other documents, such as insurance policies, to determine liability and eligibility for insurance coverage.
2. Examine claims and associated documents to determine validity and accuracy.
3. Investigate claims to identify any discrepancies or discrepancies in the claims process.
4. Analyze data to determine the total amount of the claim and ensure that all proper documents are in place.
5. Contact insureds, employers, physicians and other sources to obtain additional information needed to process claims.
6. Calculate and pay claims according to established policies and procedures.
7. Monitor claim processing and adjust payment amounts if needed.
8. Prepare and submit reports to management regarding claim status and other related information.
9. Review medical bills for accuracy and completeness.
10. Maintain detailed records of all claims activities.

Skills and Competencies to Have

1. Knowledge of state and federal laws governing insurance claims.
2. Ability to interpret and apply policy provisions.
3. Proficiency in claims processing software.
4. Strong communication and customer service skills.
5. Ability to work independently and meet deadlines.
6. Analytical and problem-solving skills.
7. Attention to detail and accuracy.
8. Ability to review and assess complex information quickly and accurately.
9. Knowledge of medical terminology and coding systems.
10. Knowledge of medical insurance reimbursement systems and procedures.

Good communication skills are essential for a Claims Examiner to be successful. The ability to effectively communicate with customers, co-workers, and supervisors is essential in order to accurately assess a claim and ensure that all parties involved are kept up to date on the progress of the claim. being able to effectively listen to customers and co-workers is important in order to understand the details of the claim and identify any potential issues that need to be addressed.

Furthermore, strong analytical skills are necessary for a Claims Examiner in order to properly evaluate the facts of a claim and determine a course of action. Lastly, having excellent problem-solving skills is also essential in order to resolve any disputes or discrepancies which may arise during the claims process. These skills, when combined, enable a Claims Examiner to quickly and accurately assess a claim and ensure that all involved parties are satisfied with the results.

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Frequent Interview Questions

• What experience do you have with claims examination?
• What techniques do you use to assess claims?
• How do you ensure accuracy when examining claims?
• In what ways do you stay informed of the latest changes in the insurance industry and how do you apply them to your work?
• How do you educate claimants about their rights and responsibilities?
• Describe a successful claim you have examined and the resolution.
• Describe a time when you had to investigate a complex claim and how did you handle it?
• How do you approach difficult claimants?
• What have been some of the most challenging claims you have had to examine?
• What measures do you take to prevent errors when examining claims?

Common Tools in Industry

1. Microsoft Excel. Microsoft Excel is a spreadsheet program used to store and analyze data. (e. g. creating pivot tables to identify trends in claim data).
2. Claims Management Software. Claims management software is used to automate and streamline the claims process. (e. g. tracking claims, managing payments, and generating reports).
3. Data Visualization Tools. Data visualization tools are used to present data in an easy-to-understand format. (e. g. creating graphs and charts to illustrate trends in claim data).
4. Document Management System. Document management systems are used to store, organize, and access claims documents. (e. g. securely archiving and retrieving claims information).
5. Statistical Analysis Software. Statistical analysis software is used to analyze and interpret large sets of claims data. (e. g. running regressions to identify correlations between claims and outcomes).

Professional Organizations to Know

1. American Academy of Professional Coders
2. National Association of Professional Benefit Administrators
3. National Association of Medicare Auditors and Program Integrity Specialists
4. American Society of Medical Claims Examiners
5. Professional Liability Underwriting Society
6. American Association of Healthcare Administrative Management
7. American Health Information Management Association
8. National Association of Insurance Commissioners
9. International Association of Industrial Accident Boards and Commissions
10. American Association of Medical Billers and Coders

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Common Important Terms

1. Liability Insurance. An insurance policy that provides protection to an individual or business against claims resulting from injuries or damages caused by the insured to another party.
2. Health Insurance. An insurance policy that provides financial protection against medical expenses incurred as a result of illness or injury.
3. Claims Adjuster. A person who evaluates and settles insurance claims on behalf of an insurance company.
4. Risk Management. The process of identifying, assessing, and controlling potential losses due to risks.
5. Insurance Coverage. The amount of risk or loss covered by an insurance policy.
6. Claims Processing. The process of collecting and evaluating information related to an insurance claim in order to determine its validity and the amount to be paid out.
7. Reinsurance. A form of insurance in which an insurer transfers part of the risk it has assumed to another insurer in exchange for a premium.

Frequently Asked Questions

What is a Claims Examiner?

A Claims Examiner is a professional who reviews and evaluates insurance claims to ensure they are processed according to the terms of the policy and applicable laws.

What types of claims do Claims Examiners handle?

Claims Examiners typically handle both property and liability claims, including health, auto, homeowners and life insurance claims.

What skills are needed to be a successful Claims Examiner?

Claims Examiners need to have excellent organizational, communication and problem-solving skills, and must be able to analyze and interpret complex information. They also need to be knowledgeable about the insurance industry and related regulations.

What is the typical salary of a Claims Examiner?

According to PayScale, the average salary for a Claims Examiner is $49,863 per year.

How long does it take to become a Claims Examiner?

It can take anywhere from several months to several years to become a Claims Examiner, depending on the level of experience and qualifications. Most Claims Examiners have completed a bachelor’s degree in a related field and have several years of experience in the insurance industry.

What are jobs related with Claims Examiner?

• Property and Casualty Insurance Agent
• Long-term Care Insurance Agent
• Insurance Examiner
• Insurance Pricing Analyst
• Claims Adjuster Supervisor
• Reinsurance Broker
• Insurance Compliance Officer
• Insurance Salesperson
• Claims Supervisor
• Life Insurance Agent

Web Resources

• Health Claims Examiner - Galaxy Medical College galaxymedicalcollege.edu
• Claims Examiner – TEAMS Titles teams-titles.hr.ufl.edu
• How to Become a Medical Claims Examiner | Brookline College www.brooklinecollege.edu