Main Responsibilities and Required Skills for Claims Examiner
A Claims Examiner is responsible for handling insurance claims in accordance with the company's guidelines. They review incoming claims, evaluate coverage, and perform detailed investigations. In this blog post we describe the primary responsibilities and the most in-demand hard and soft skills for Claims Examiners.
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Main Responsibilities of Claims Examiner
The following list describes the typical responsibilities of a Claims Examiner:
Adhere to
Adhere to all Company policies and procedures.
Adjudicate
Adjudicate claims for fair and reasonable repair charges.
Adjudicate new and existing Accident & Health claims.
Adjust
Adjust claim from inception to completion in a proactive manner.
Administer
Administer claims payments / settlements through trust accounts.
Advise
Advise all interested parties of the status during the claim process.
Analyze
Analyze and draft coverage letters as appropriate and communicates coverage positions effectively.
Analyze claims activities and prepares reports for clients, carriers and / or management.
Analyze claims activity and prepares reports for clients / carriers and management.
Analyze complex issues and make critical decisions.
Analyze insurance contracts.
Analyze suspect insurance claims.
Answer
Answer claims and coverage questions from other departments.
Answer incoming phone calls and emails from service providers seeking repair authorizations.
Assess
Assess liability and resolves claims within evaluation.
Assess first party property and third party liability claims on a nationwide basis.
Assign
Assign and confer with legal counsel on claims requiring litigation.
Assist
Assist in claim inquiries and ensure all claims are promptly investigated.
Assist in handling client complaints.
Assist leadership team in improving department processes, training, and turnaround times.
Assist supervisor and company attorneys in preparing cases for litigations.
Assist the Insurance Manager, Senior Examiner, and other Insurance staff as necessary.
Attain
Attain objectives of assigned projects and benchmarks for claims processing and file closure.
Attend
Attend mediation and settlement conferences.
Attend mediations, arbitrations, pre-trial conferences.
Attend training as necessary to ensure skills evolve with changes in the industry.
Calculate
Calculate and assigns timely and appropriate reserves to claims.
Calculate and pays benefits due.
Calculate interest and / or expense to ensure accuracy.
Calculate settlement adjustments as necessary.
Collaborate with
Collaborate and discuss with internal business partners to come to a sound decision.
Collect
Collect, interpret, and input data efficiently and accurately.
Communicate
Communicate claim activity and processing with the claimant and the client.
Communicate in a timely and effective manner with all parties involved in the claim process.
Communicate suggestions for improvement and efficiencies to management.
Communicate the Company's position regarding the claim.
Communicate with claimants, providers and vendors regarding claims issues.
Communicate with the public.
Complete
Complete benefits package is available.
Complete outside investigation as needed per case specifics.
Conduct
Conduct, coordinate, and direct investigation into loss facts.
Conduct, coordinate, and proactively direct investigation, defense and settlement of claims.
Conduct file reviews independently.
Conduct legal research and monitor trends in the personal injury field.
Conduct on-site second vehicle inspection for Auto property damages claims.
Conduct telephone calls to health and dental service providers for incomplete claims information.
Conduct training and mentors new hires.
Confer
Confer and direct legal counsel on claims requiring litigation.
Confirm
Confirm coverage of claims by reviewing policies and documents submitted in support of claims.
Contact
Contact other associates or clients to help resolve / correct data discrepancies.
Contribute to
Contribute effectively to the accomplishment of team or work unit goals, objectives and activities.
Contribute to team effort by accomplishing related results as needed.
Coordinate
Coordinate services with vendors and service providers.
Coordinate vendor referrals for additional investigation and / or litigation management.
Create
Create reports for internal departments on claims.
Delegate
Delegate settlement authority to adjustors.
Demonstrate
Demonstrate customer service commitment by timely response to calls, emails and letters.
Determine
Determine eligibility of claims and amounts owed under the terms of the contract.
Determine family coverage and issue endorsements accordingly.
Determine verification of coverage.
Determine when to escalate concerns to the appropriate level of management.
Develop
Develop and employ creative resolution strategies.
Develop subrogation and third party recovery potential and follows reclaim procedures.
Direct
Direct Field Adjusters on task assignment investigations.
Direct responsibility for supervision of all subrogation and arbitration handling.
Direct and closely monitor assignments to experts and defense counsel.
Direct the discovery and litigation strategy with legal counsel.
Discuss
Discuss and present difficult or complex claims before pairs and management.
Document
Document all non-standard processes in the claim notes.
Ensure
Ensure claim files are properly documented and claims coding is correct.
Ensure coordinated and timely investigation through communication with the control adjusters.
Ensure corresponding denial letters are accurate.
Ensure high level of customer service and technical claim file quality.
Ensure that a file is proceeding towards a prompt, fair and equitable claim settlement.
Ensure timely and cost effective claims resolution.
Establish
Establish accurate reserves.
Establish and maintain effective working relationships with those contacted in the course of work.
Establish and maintains proper indemnity and expense reserves.
Establish claim reserves and issue claim payments.
Evaluate
Evaluate all claims for recovery potential.
Evaluate and sets reserves using independent judgment.
Evaluate coverage and perform detailed claim investigations.
Evaluate relevant information from sources such as lawyers, medical providers and other experts.
Examine
Examine moderate to intermediate complex property claims.
Follow
Follow oral and written directions.
Follow policies and procedures in order to maintain efficient and compliant operations.
Handle
Handle all complicated litigation and critique trial preparation with attorneys.
Handle claims in accordance with established corporate best practices and claim handling guidelines.
Handle higher degree of complex losses within assigned authority limits.
Handle research assignments and reporting as delegated by management.
Handle special projects as assigned.
Handle telephone calls, emails and letter inquiries.
Identify
Identify subrogation opportunities, handle and manage recovery claims against appropriate parties.
Initiate
Initiate and conduct investigation in a timely manner.
Interpret
Interpret and apply laws, rules and regulation, as well as complex policy and contract coverage.
Interpret policy wordings, determine policy coverage and ensure appropriate reserving.
Interview
Interview witnesses and take necessary statement.
Investigate
Investigate, research and apply critical thinking to claims in question.
Liaise with
Liaise with all stakeholders to insure clients needs are met.
Maintain
Maintain a 30 day follow up for all pending claims and send follow-up requests.
Maintain accurate records based on company standards and policies within the claims system.
Maintain all required documentation of claims processed and claims on hand.
Maintain an active file load.
Maintain an appropriate diary date on files under direct supervision.
Maintain and develop strong, positive relationships with lawyers and industry professionals.
Maintain claim files in an organized fashion.
Maintain compliance with regulations and respond to any insurance department complaints.
Maintain confidentiality of all policies information and adhere to company's privacy regulations.
Maintain established claims management in line with best practices.
Maintain knowledge of covered equipment, as relates to the price / replacement value.
Maintain production standard.
Maintain professional client relationships.
Maintain records, prepare reports and conduct correspondence related to the work.
Maintain regular and predictable attendance.
Maintain timely and accurate claim reserves on files.
Maintain vendor relationships and monitor performance of vendor partners.
Make
Make accurate payment decisions according to adjudication guidelines.
Make denial / approval of claims per the terms and conditions.
Make corrections within accepted parameters and escalate unresolved discrepancies to supervisor.
Manage
Manage a high volume of claims while maintaining established turnaround performance guarantees.
Manage all aspects of investigative activity on complex claims.
Manage claims through well-developed action plans to an appropriate and timely resolution.
Manage medical treatment and medical billing, authorizing as appropriate.
Manage reserve adequacy throughout the life of the claim.
Manage the litigation process.
Manage the review of a claim and the outside sources used in the review.
Meet
Meet and / or exceed qualitative and quantitative production standards.
Monitor
Monitor the course of the investigation.
Negotiate
Negotiate disposition of claims with insureds and claimants or their legal representatives.
Negotiate first party settlements directly with insurers.
Negotiate settlement of claims within designated authority.
Negotiate with insureds, claimants, lawyers and insurers.
Participate in
Participate in client review and Profit Centre meetings.
Participate in company marketing initiatives as required.
Participate in process improvement activities.
Perform
Perform other duties as assigned.
Prepare
Prepare a detailed explanation in the event of claim denial.
Prepare necessary state fillings within statutory limits.
Prepare proposed expense and loss reserve / settlement reports that exceed authority for submission.
Prepare reports to management and reinsurers.
Prepare written correspondence and reports as required.
Process
Process and assure correct settlement of routine death claims.
Process claims involved with Claim Enhancement Project (CEP).
Process entry level and high level Medicare Supplement claims.
Process payment for approved claims via ACH, wire transfers or check.
Process payment to physicians and to medical facilities.
Produce
Produce reports with occasional guidance from Manager.
Provide
Provide a high standard of customer service and adherence to legal and regulatory requirements.
Provide appropriate and timely communication while maintaining confidentiality.
Provide consulting and training resources for field and internal business partners.
Provide consulting and training resources for internal business partners.
Provide exceptional customer service.
Provide file review feedback and in some cases direction on file completion.
Provide ongoing technical advice and guidance to junior and independent adjusting staff.
Provide technical assistance and direction to your team members and be a party to their success.
Pursue
Pursue the most effective means of investigating Credit Protection claims.
Receive
Receive claim facts from sites (or wherever the claim arises).
Recognize
Recognize and pursue subrogation where warranted.
Recognize early death claims to be escalated.
Recommend
Recommend, attend, and / or present at claims roundtable for collaboration of technical expertise.
Report
Report back to the syndicate or self-insured according to their guidelines.
Report claims to the excess carrier.
Report trends to the Manager of Insurance.
Research
Research and stay up-to-date with trends and changes in the claims / insurance industry.
Research claims to determine what coverage options were purchased.
Respond to
Respond to requests of directions in a professional and timely manner.
Review
Review all incoming claims to verify necessary information.
Review all received claim documentation.
Review amounts on all estimates, invoices and documentation in support of payments.
Review and analyze adjuster's reports, ensuring compliance / accuracy and efficiency.
Review and evaluate claims for appropriate coding against charges that are being billed.
Review and processes claims acknowledgment, payment and denial as set forth by CMS, Healthplans.
Review claims reports of high complexity to ensure accurate records are produced and distributed.
Review fees for accuracy and quality.
Review independent adjuster reports for accuracy.
Review of multiple surgical procedures and establishment of reasonable and customary fees.
Review, verifies, and confirms claims.
Strategize
Strategize and take action to obtain best possible results for claims.
Support
Support all marketing and client / customer service initiatives.
Support defense counsel on third party litigation where necessary.
Support the organization's quality program(s).
Take
Take all initial steps to resolve questions that arise from the above action.
Take their call and prepares the customer information needed to start their claim.
Target
Target identification of subrogation opportunities and lead recovery efforts.
Understand
Understand complex policy and contract coverage.
Understand principles and practices of insurance claims examination.
Use
Use computer and related software effectively.
Use Microsoft Office programs efficiently and effectively.
Utilize
Utilize systems to track complaints and resolutions.
Verify
Verify loss details and confirm coverage related to assigned claims.
Work
Work autonomously within established guidelines.
Work independently and demonstrate drive and initiative.
Work within agreed decision making standards, limitations and authorities.
Work within established authority on moderate-to-difficult claims.
Most In-demand Hard Skills
The following list describes the most required technical skills of a Claims Examiner:
Diary Management
Common Law Claims
Consistent Policy Wording Interpretation
Enabling Accurate
Manage and Prioritize Workload
Policy Language
Effectively Following Up on Recommendations from Technical Claims Audits
Work with claims stakeholders to effectively direct claims strategy
Most In-demand Soft Skills
The following list describes the most required soft skills of a Claims Examiner:
Written and oral communication skills
Analytical ability
Time-management
Organizational capacity
Problem-solving attitude
Attention to detail
Contribute effectively within a team environment
Team player
Work independently with little direction
Interpersonal skills
Negotiation
Work under pressure
Multi-task
Work in a team environment
Self-motivated
Solve problems
Act with speed
Compassion
Integrity
Policy language interpretation
