Claim Examiner Job Description
Claim Examiner Duties & Responsibilities
To write an effective claim examiner job description, begin by listing detailed duties, responsibilities and expectations. We have included claim examiner job description templates that you can modify and use.
Sample responsibilities for this position include:
Claim Examiner Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Claim Examiner
List any licenses or certifications required by the position: AIC
Education for Claim Examiner
Typically a job would require a certain level of education.
Employers hiring for the claim examiner job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Collage Degree in Education, Business, Graduate, Technical, Graduate Education, High School Education, Military, Associates, Financial Services, Keyboard Skills
Skills for Claim Examiner
Desired skills for claim examiner include:
Desired experience for claim examiner includes:
Claim Examiner Examples
Claim Examiner Job Description
- Calculates and assigns timely and appropriate reserves to claims
- Reports claims to the excess carrier
- Adjudicate all aspects of travel claims within stated authority
- Field and respond to claims-related calls, emails and other correspondence from insureds, providers and accounts
- Promptly and thoroughly investigates and evaluates claims within departmental and regulatory guidelines
- Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations
- Promptly and thoroughly investigates claims within departmental and regulatory guidelines
- Fully investigate all relevant claim issues, provide payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations
- Recognize and pursue recovery
- Respond to written inquiries from policyholders, beneficiaries, attorneys and families of deceased employees
- Industry education credentials such as FLMI, ALHC, a plus
- A wide degree of initiative and judgment is expected
- Completion of a professional designation in the insurance field a plus
- Provide high quality, timely service to policyholders, beneficiaries, attorneys, families of deceased employees and administration
- Directs the discovery and litigation strategy with legal counsel
- CIP or FCIP Industry designation
Claim Examiner Job Description
- Ensure the establishment, documentation, and execution of appropriate strategies to bring early resolutions to assigned claims
- Proper use and direction of TPA personnel and oversight of management of approved vendors
- Although the file handler’s request for reserve and settlement authority will be submitted to the TPA management this Examiner will sit on the LL panel and weigh in on reserve recommendations
- The claim examiner will document his/her activities on all their pending cases in the RIMS system
- The examiner will ensure that all reporting requirements by our carrier and/or our company are met by the file handler
- The examiner may be asked to track or generate TPA reports for a variety of metrics for the department, such as lag time, pending per adjuster
- The examiner will give the necessary direction to the claim handler to ensure that the file quality meets or exceed 90%
- The examiner will bring any quality or handling issues to the attention of the claim management staff
- The claim examiner may be involved in training claim personnel or collaborating with other team members concerning training modules to be rolled out and/or implemented
- The examiner will assist the file handlers in ensuring that sound litigation management occurs and that the performance of external counsel is moving a file to the most direct and cost-effective resolution
- University Degree or College Diploma or equivalent Property technical work experience
- Superior technical claims handling
- Demonstrated customer service commitment
- Technical competence in Personal and Commercial insurance
- Strong communication skills – ability to communicate diplomatically and empathetically
- Ability to negotiate and reach agreement with suppliers/vendors
Claim Examiner Job Description
- Maintain a diary for all files assigned by the Liability or Corp Claim Director
- Advise Liability or Corporate Claim Director of any issues that may come up with any vendors that are assisting on the file or in the department
- Prepare reports for submission to Senior Management
- Proper use and direction of TPA personnel and oversight of management of approved WC vendors
- Although the file handlers' requests for reserve and settlement authority will be submitted to the WC Director, the claim examiner will assist the WC Director with these requests by sharing any information that they have found during their oversight of the case
- The examiner may be asked to track or generate TPA reports for a variety of metrics for the WC Director, such as lag time, pending per adjuster
- The examiner will give the necessary direction to the claim handler to ensure that the file quality meets or exceeds 90%
- The examiner will be involved in ensuring that locations follow the WC FORM process and/or may be involved in training of our locations concerning the WC FORM process
- Maintain a diary for all files assigned by WC Director
- Advise the WC Director of any issues that may come up with any vendors that are assisting on the file or in the department
- Ability to adopt business strategies and manage ongoing changes
- Regional licensing requirements for New Brunswick, Newfoundland and Prince Edward Island are necessary for this role
- Shares information and engages in candid and open dialogue
- Business-Insurance Studies preferred
- Adjuster’s License preferred
- Liability Investigation Techniques
Claim Examiner Job Description
- Reviews high volume of claims information on appropriate claims application(s) and ensures compliance with any local service standards to maintain accurate records for Claims Advisory
- Identifies potential policies and coverages for incoming claims, performing independent research to seek validation or clarification where necessary to add leverage to Claims Advisory and support claims analysts
- Investigate, evaluate, and resolve claims of varying complexity and severity
- Frequent interaction with senior management, Corporate Claims, and others, will be required
- Lead and manage team to process claims by determines liability, secures information, reviews coverages, calculate claim quantum and claim decisions and settlements follow regulatory requirement and policy term and conditions
- Escalate potential issues / complaints, issues /complaints and or special requests from customer / producers to Claims Assistant Manager if any
- Assist in the development of newly hired Claims staffs if any
- Reviews claims reports of high complexity to ensure accurate records are produced and distributed
- Distributes new claims notifications and updates to the team in order to ensure information shared is consistent and clear
- Creates standard templates for insurance claims forms and reviews templates for effectiveness to ensure consistent deliverables are produced by support staff
- Human Resource Management preferred
- Insurance Principles/studies preferred
- Worker's Compensation Investigation Techniques
- Worker's Compensation Insurance Principles
- Interface with assistance providers
- Handle subrogation and coordination of benefits
Claim Examiner Job Description
- Manage a caseload of commercial property claims including Catastrophic, Ocean Marine, Aviation
- Evaluate and settle claims, applying technical knowledge and people skills to effect fair and prompt claim resolution
- Promotes a positive customer service image through prompt, accurate and courteous responses to customer information needs
- Consistently adheres to the documented workflow guidelines and established procedures
- Maintains required levels of confidentiality
- Demonstrates competency in all modules of training program
- Interprets and administers contract provisions including, but not limited to, eligibility, covered weekly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations
- Calculates benefit and identifies other income replacement benefits
- Assists in the subrogation process to recover money from third parties
- Works in coordination with an LTD Examiner to ensure an appropriate transition from the STD claim to LTD
- Ability to take part in active strategic discussions
- Proper Adjuster Licenses in applicable states
- College Degree preferred or related business background
- Claims experience (5 years or more), some LOMA or ICA preferred
- Aptitude to quickly understand the Divisional claims policies, procedures and philosophies and to gain knowledge of the Life and Annuity products and policy provisions
- Strong working knowledge of computer system familiarity