Claims Examiner Job Description
Claims Examiner Duties & Responsibilities
To write an effective claims examiner job description, begin by listing detailed duties, responsibilities and expectations. We have included claims examiner job description templates that you can modify and use.
Sample responsibilities for this position include:
Claims Examiner Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Claims Examiner
List any licenses or certifications required by the position: SIP, AIC, I.E.A, S.I.P, FML, ANFI, WCCA, CPC, CCP, PGI
Education for Claims Examiner
Typically a job would require a certain level of education.
Employers hiring for the claims examiner job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Business, Education, Associates, Legal, Technical, Management, Communication, English, Financial Services, Continuing Education
Skills for Claims Examiner
Desired skills for claims examiner include:
Desired experience for claims examiner includes:
Claims Examiner Examples
Claims Examiner Job Description
- Process claims involving medical and/or surgical services
- Apply administrative policies when necessary, utilizing the claims processing manuals
- Authorize the generation of letters / questionnaires to providers to obtain additional information
- Review descriptions of services on claim to determine validity of charges or the presence of errors
- Evaluate and examine claims pended by the system due to contractual and/or payment discrepancies
- Maintain production and quality goals established for the department
- Makes Coverage Decisions based upon SFIP and FEMA language and rules
- Reviews System work queues, promptly enters or updates data into System in compliance with established processes
- Adjudicates moderate to highly complicated Payment Protection claims and determines if benefits are payable or not
- Prepares letters and requests any information needed to make a determination on claims from insurance carrier, family, claimant, physicians, employers, and others
- Negotiate with plaintiff attorneys, insurance companies, to settle vehicle and/or personal injury claims within your individual authority limits
- At least 1-3 years of claims insurance experience
- Manages a caseload of claims
- Monitors the medical treatment of claimants
- Teamwork - Rating is based upon individual contribution to both the group and the goals of the group
- Support Supervisors/Manager with Reports, Special Processes
Claims Examiner Job Description
- Conducts investigation to determine if application is for compensable crime, and to determine applicant's eligibility for compensation
- Reviews medical reports, law enforcement investigative reports, mental health provider's treatment plan or session notes, witness and applicant voluntary statements, and any other pertinent documents to determine whether these documents substantiate crime
- Obtains additional necessary information by contacting directly or corresponding with applicant, witnesses, law enforcement, victim advocates, criminal justice personnel, employers and medical and mental health providers
- Determines denial of application for cases that do not meet statutory eligibility or are fraudulent
- Process complex claims in various queues
- Process claims, involving communications with participating plans and/or Service Units
- Periodic overtime may be required at the sole discretion of the employer based on business need
- Communicate and interact effectively and professionally with co-workers, management, customers
- Analyze accidental death reports for life claims, , accident reports, medical examiner reports, toxicology reports
- Managing key claims handling enquiry
- Some college courses or related field preferred
- Must have at least two (2) year claims processing or related experience
- Must be able to type at least 40 WPM accurately and know 10 key by touch
- Must have working knowledge of word processing and spreadsheets preferably in Microsoft Word and Excel
- Must be able to draft business letters
- Must be able to prioritize job duties and be detail oriented
Claims Examiner Job Description
- Extensive commercial auto, general/product liability and construction defect
- This position is for property vendor management
- This position primary task are handling vendor related issues, contracts, reporting, issue resolution, and specialty projects
- This position is responsible for the review of high exposure claim files to ensure reserves are properly set and maintained, demands are handled appropriately and regulatory standards are adhered to for compliance
- This position handles complex claims matters involving property lines of insurance written by the Interinsurance Exchange in compliance with all regulatory and statutory requirements
- This position includes review of processes for investigation, evaluation and settlement of high complexity
- This position ensures effective communication with internal and external customers, communicate and interact with a variety of individuals to address issues in prompt and professional manner
- This position will be a member of the Examination Team
- Complete special projects or research as assigned by the Claims Manager
- The position will perform related duties in support of the Claims Business unit for all Markets and will assist the Examination Team and the Technical Regional Manager in producing statistical reports to assist in the analysis of tends related to severity and expense management
- Experience with Facet's a plus but not a requirement
- Completed Blue Chip Claims Processing System training, or have the ability to fully complete the 6 - 8 week training class
- Minimum of 2 years managed care experience
- Exceptional written, telephonic, and oral communication (public speaking), leadership, problem-solving, interpersonal, and organizational skills required
- High School/GED Certificate
- Must have trained on the six-eight week Blue Chip claims processing system, or have the ability to fully complete the six-eight week Blue Chip Training class
Claims Examiner Job Description
- Identifies frequently recurring situations at customer level, escalates such situations and suggests remedial actions
- Applies fundamental collection techniques and adjusts collection strategies to the requirement of the portfolio
- Maintains knowledge of the business area of the client that is supported
- Issues and monitors automatic and manual reminders to customers
- Performs customer account reconciliations
- B2C4.1.2 Collect From Tier 2 Customer (Medium Risk, Standard)
- B2C4.1.3 Collect From Tier 3 Customer (Low Risk, Small)
- B2C4.1.4 Retained Collection
- B2C4.1.5 Escalate unpaid amounts
- B2C4.1.7 Create and send statement
- Insurance qualification preferred
- Underwriters and legal counsel
- Possession of state adjuster licenses is preferred
- A minimum of 3 at Grade C or above including Mathematics and English
- Knowledge of master contracts
- Knowledge of provider and ancillary pricing contracts
Claims Examiner Job Description
- Must have some understanding of Microsoft Excel (Pivot Tables, Formulas, etc)
- Oracle PO/Invoicing is a plus
- Using a PC /Microsoft Window environment
- Adjudicates claims with the aid of the Facets and Macess Systems
- Reviews and ensures the accuracy of all provider, member and claim line information for all claims for which the examiner is responsible
- Reviews and ensures the accuracy of all changes to claim line information based on information received from other departments and in accord with available benefit information
- Responsible for the timely and accurate adjudication of claims that are suspended to other departments for benefit and/or authorization determination
- Meets or exceeds department quality and work management standards for claims adjudication
- Successfully completes a course of comprehensive formal training in all areas of benefits determination, system navigation, and policy
- Suspends, investigates and resolves claim issues by coordinating with appropriate departments, based on criteria set by those departments
- Acquiring adjuster licenses or related may be required, depending upon country/jurisdictional requirements
- Knowledge of Facets system and Facets Benefit Summary files
- Knowledge of corporate business rules, programs, and systems
- Quickly learn product language and provisions
- Degree holder or equivalent with 3 years of experience required
- Holds a BCP and PGI certification