Main Responsibilities and Required Skills for a Claims Analyst

A Claims Analyst is a professional who plays a crucial role in the insurance industry. They are responsible for evaluating insurance claims, investigating their validity, and determining the appropriate compensation for policyholders. Claims Analysts work closely with insurance adjusters, policyholders, and other stakeholders to ensure fair and accurate claims processing. In this blog post, we will describe the primary responsibilities and the most in-demand hard and soft skills for Claims Analysts.

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Main Responsibilities of a Claims Analyst

The following list describes the typical responsibilities of a Claims Analyst:

Adapt to

Adapt to changing priorities and handle multiple claims concurrently.

Adjust

Adjust physical damage claims including unreported damage claims.

Aid in

Aid in the evaluation of workload and strategic planning for current and future business growth.

Analyze

Analyze and investigate complicated insurance claims to help prevent fraud.
Analyze claim data, such as medical records or property damage assessments.
Analyze claim resubmissions to determine areas for provider education or system re-configuration.
Analyze claims-related data to identify patterns and improve claims processes.
Analyze foreign currency exchange exposure.
Analyze provider issues and collaborate with other departments to resolve.

Answer

Answer service requests and inquiries received from various channels.

Assess

Assess Insurance claim coverage, liability, and quantum.
Assess loan insurance claims.

Assist in

Assist in developing claims and appeal / grievance overviews and status reports.
Assist in identifying and analyzing problems.
Assist in the development and implementation of claims management strategies.
Assist with client claim file audits requested by our client(s).
Assist with other risk management and insurance related projects as required or requested.

Attend to

Attend meetings as required, and participates on committees as directed.
Attend to third party material damage claims in line with set procedures.

Batch

Batch completed claims for submission to HUD.

Calculate

Calculate claim settlements based on policy coverage and applicable deductibles.

Check

Check own work, coordinates work with related disciplines.

Collaborate with

Collaborate with insurance adjusters to assess the extent of covered losses.
Collaborate with underwriters to analyze claim trends and provide feedback for policy improvements.

Communicate

Communicate and execute on initiatives in partnership with Senior Claims Manager.
Communicate claim decisions and settlement offers to policyholders.
Communicate effectively with internal and external customers on claims and account issues.
Communicate immediately to leadership all obstacles to completing work.
Communicate often with members and suppliers and must exceed clients' satisfaction expectations.
Communicate results effectively with internal and external contacts.
Communicate with insureds, brokers, defense counsel, and other involved parties.

Compile

Compile and organize various scheduled and ad-hoc reports in an accurate and timely manner.

Complete

Complete investigations – report / escalate risk issues or process gaps identified.
Complete straight through process for claims that meet the eligibility requirements.

Conduct

Conduct a thorough investigation of coverage, liability and damages.
Conduct claim testing for CPHL products.
Conduct phone intake interviews and reviews legal information pertaining to civil claims processes.
Conduct quality assurance checks to maintain accuracy and consistency in claims processing.
Conduct thorough investigations to validate the accuracy and legitimacy of claims.

Contribute to

Contribute to a fair, positive and equitable environment that supports a diverse workforce.
Contribute to business objectives for Operational Excellence.

Coordinate

Coordinate department meetings maintain meeting schedules.
Coordinate with external experts, such as medical professionals or legal advisors, for specialized claim evaluations.

Cross

Cross train in multiple areas and perform all other duties as assigned by management.

Define

Define project scope, business requirements, goals and deliverables.

Determine

Determine liability and value of claim, set reserves accordingly, establish resolution plan.

Develop

Develop and implement claim management and return to work strategies for their assigned caseload.
Develop and implement claim management and return to work strategies for your assigned caseload.
Develop awareness of the overall Project's scope, schedule and budget.
Develop process documentation to support procedural changes within the Claims department.
Develop successful partnership with Claims staff.

Discuss

Discuss accidents, damage, preventability and processes with commercial vehicle operators.

Document

Document evaluation, thought process, and strategy.

Download

Download, review, and redact incoming documentation in response to charge-back notifications.

Ensure

Ensure adherence to company SOP, policies and guidelines at the project level.
Ensure compliance by legal counsel of our litigation guidelines.
Ensure compliance with company policies, procedures, and legal requirements.
Ensure compliance with Federal and Bank Regulations.
Ensure customer problems are handled appropriately and escalating issues when necessary.
Ensure delivery of existing service level agreements and loss assessment of auto claims.
Ensure necessary due diligence to support the accuracy of all customer transactions / activities.
Ensure Property Claims operation compliance with local regulations.
Ensure that all policies and procedures for the claims Department are followed and maintained.
Ensure that all teams across Warranty receive regular training on fraud identification and reporting.
Ensure timely and accurate reporting of exposure.

Enter

Enter notes from other staff members.

Escalate

Escalate non-standard or high risk activities as necessary.

Establish

Establish appropriate loss and expense reserves with documented rationale.

Evaluate

Evaluate catastrophic or regional events that would lead to or drive increased fraud activity.
Evaluate exposures and make substantive claim decisions.
Evaluate insurance claims to determine coverage and policy limitations.

Facilitate

Facilitate insurance renewal process.

File

File work comp board forms for any disputed or controverted claims.

Focus on

Focus on career development and internal promotion.

Follow-up

Follow-up with clients to ensure timely and accurate submission of documentation.

Follow

Follow written procedures and scripts.

Foster

Foster a culture of transparency and trust.
Foster positive relationships with policyholders, agents, and other stakeholders.

Give

Give guidance to insured and / or broker to manage expectations.

Handle

Handle and process claims transactions accurately and efficiently.
Handle daily contact with facility.
Handle escalated customer situations that were unable to be resolved by the initial claims analyst.
Handle Fast Track Auto, Residential and Accident benefits claims.
Handle periodic reconciliation reports.

Identify

Identify and report property claims risks.
Identify claims with potential recovery.
Identify contractual and administrative adjustments.
Identify issues and escalates internally.
Identify needs and proactively seek coaching to generate improvement opportunities.
Identify potential fraudulent claims and report findings to the appropriate authorities.
Identify value adding opportunities for risk management functions.

Implement

Implement departmental procedures and directives.

Interface with

Interface with insureds, brokers and counsel to resolve claims.

Interpret

Interpret policy terms and conditions to guide claim decisions.

Investigate

Investigate and coordinate insurance benefits for insurance claims across multiple service lines.
Investigate claims promptly and thoroughly.
Investigate data inconsis.
Investigate / Evaluate coverage, litigation management and settlement negotiation.

Issue

Issue payments within appropriate time frame.

Keep

Keep sensitive claim information confidential and adhere to data protection protocols.

Lead

Lead monthly internal claim reviews with Business assigned.
Lead the management of medical only and non-litigated workers compensation claims.

Liaise with

Liaise directly with the customer to discuss requests.
Liaise with our underwriting department with respect to insureds and claims.
Liaise with providers for clarifications on requests.
Liaise with various stakeholders to facilitate project timelines and deliverables.

Load

Load insurance and queue bills in hospital system.

Locate

Locate employer / insurance information and first report of injury.

Look

Look for ways to contribute to the on-going improvement of the overall customer experience.

Maintain

Maintain accuracy of claims data and loss history in electronic claims system.
Maintain accurate records of claim activities and decisions.
Maintain an accurate and complete record of claim movements as verified against loss support.
Maintain and manage a diary system to efficiently manage and resolve assigned claim inventory.
Maintain and update vendor programs / claims procedures to improve efficiencies.
Maintain a positive demeanor and foster team spirit.
Maintain a positive image when dealing with department personnel and other employees.
Maintain high standards of customer service.
Maintain scanning and indexing of documents.

Make

Make presentations to both claim and underwriting management.
Make regular and appropriate contact with internal and external customers.

Manage

Manage claims in litigation.
Manage complex D&O, E&O, EPL, Financial Institutions, Fidelity, Fiduciary claims.
Manage diary timely to ensure that cases move to the best financial outcome and timely resolution.
Manage reserve adjustments and payments to avoid deficit payments.
Manage stakeholder relationships to develop and validate business requirements.
Manage the setup of new claims by identifying appropriate insurance policies and / or coverage.

Meet

Meet and exceeds departmental expectations for accuracy and productivity.

Monitor

Monitor and track claim reserves to ensure adequate funds are set aside.
Monitor changes across the industry for early warning signs and to institute organizational learning.

Negotiate

Negotiate settlements directly where possible.
Negotiate settlements with policyholders or their legal representatives.

Obtain

Obtain supporting documentation regarding insurance follow-up efforts.

Participate in

Participate in claim review meetings and provide insights for process enhancements.
Participate in mediation / ADR process to bring about resolution of claim.
Participate in negotiations and manage projects.
Participate in risk management seminars and company events.
Participate in special projects to support Regional and National management as required.
Participate in the Quality Assurance reviews from time to time.
Participate in training programs and professional development activities to enhance skills and knowledge.

Perform

Perform additional duties and work as assigned.
Perform system configuration functions using on-line architectural tools with minimal supervision.

Plan

Plan, schedule, and track project timelines and milestones using appropriate tools.

Prepare

Prepare and provide country level reporting.
Prepare and review insurance claim forms and related documents for completeness.
Prepare and send letters to clients.
Prepare claims payment requests for presentation to Claims Manager for approval.
Prepare for and attend settlement conferences and meditations.
Prepare internal management reporting.
Prepare Large Loss reports and maintain ongoing claim updates.
Prepare memos and letters in communicating with other employees, management, and customers.
Prepare reports and presentations on claim activities, trends, and performance metrics.
Prepare reports for upper management, underwriters and actuaries as necessary.
Prepare timely coverage assessments and prepare coverage letters.

Prioritize

Prioritize and manage own workload to meet SLA requirements for service and productivity.
Prioritize and organize own work to meet deadlines.

Produce

Produce clear and effective written materials.
Produce training materials such as PowerPoint presentations, handouts and job aids.

Provide

Provide additional support as needed.
Provide clear guidelines to non-US team members to follow.
Provide coaching and training to other associates.
Provide complex analytical analysis and support on various strategies to ensure goals are met.
Provide direction to adjusters on investigation of claims.
Provide direction to independent adjusters on investigation of claims.
Provide excellent customer service.
Provide feedback on department workflows and identifies opportunities for redesign.
Provide follow up and intervention relating to provider claim inquiries.
Provide guidance and assistance to policyholders in the claims process.
Provide initial review and recommendation for claims appeals.
Provide input and prepare reports for management to monitor and validate training.
Provide input to the development of training programs for recovery.
Provide instructions to legal counsel to bring about appropriate resolution of claims.
Provide sound claims advice at every customer interaction to create a legendary customer experience.
Provide status reports to management when required.
Provide the highest level of customer service and manage reputational risk.
Provide training on Navigator, Oasis, and Claims Desk systems for new hires.

Reconcile

Reconcile claims activity from various countries.
Reconcile incoming premium payments from various countries.

Re-evaluate

Re-evaluate coverage as warranted.

Research

Research and resolve other general customer account inquiries as appropriate.

Respond to

Respond to inquiries and resolve issues related to claims from policyholders or other stakeholders.
Respond to insurance related inquiries from internal groups, lenders and suppliers / contractors.

Retain

Retain and instruct lawyers / adjusters and experts as required.

Return

Return accounts for Health Insurance billing.

Review

Review, analyze, investigate and authorize payment of health and dental claims within set guidelines.
Review and assess new claims to determine coverage and take appropriate action.
Review and process new claims reports.
Review and resolve pended and corrected claims.
Review and understand eligibility of benefits.
Review and understand EOB'S..
Review casualty claims in conjunction with policy wordings to determine coverage.
Review claim denials and provide corrections when needed.
Review claim documentation, including policies, reports, and supporting evidence.
Review claim processing results of Delegated Vendors.
Review claims for appropriate adjudication.
Review commercial auto claims in conjunction with policy wordings to determine coverage.
Review provider disputes or appeals and provide a detailed analysis of findings.

Stay updated on

Stay updated on industry regulations and changes in insurance policies.
Stay up to date on industry information, system changes, network rules and compliance requirements.

Support

Support and mentor junior claims team members.
Support change initiatives for the team and business function as required.
Support the timely and accurate completion of business processes and procedures.

Take

Take appropriate action to complete various insurance claims transactions.

Train

Train claims personnel in recovery recognition and procedures.

Travel

Travel for mediation attendance and trials as necessary.

Triage

Triage and track claims for reprocessing with claims vendor.

Troubleshoot

Troubleshoot and identify root cause of problems and participate in developing solutions.
Troubleshoot rebate application issue, sales order, and price discrepancy.

Understand

Understand and executes faithfully the LEI program and its initiatives.

Uphold

Uphold relationships and communication with insurance departments and clients.

Upload

Upload correct documentation to every database account.

Use

Use of Microsoft Access or similar query tool.
Use pertinent data and facts to identify and solve a range of problems within area of expertise.

Utilize

Utilize ADR as appropriate and necessary.
Utilize claims management software and tools for efficient and effective claim handling.
Utilize documented team processes to ensure compliance with departmental standards.
Utilize the Quality Framework to measure employee technical performance.

Verify

Verify payment scales specific to specific state fee schedules.

Work with

Work closely with operational stakeholders to properly engineer workflow.
Work with Billing Team and Systems Team to identify and resolve issues.
Work with third-party vendors, such as appraisers or investigators, as necessary.

Most In-demand Hard Skills

The following list describes the most required technical skills of a Claims Analyst:

Proficiency in insurance claim evaluation and analysis.
Strong knowledge of insurance policies, coverage types, and limitations.
Excellent investigative and research skills.
Data analysis and interpretation abilities.
Familiarity with medical terminology (for health insurance claims).
Understanding of legal principles and contracts.
Experience with claims management software and databases.
Knowledge of regulatory compliance and industry standards.
Financial analysis and mathematical skills for claim calculations.
Expertise in negotiation and settlement techniques.
Proficient in using spreadsheets and other data management tools.
Advanced problem-solving and critical-thinking abilities.
Detail-oriented with a strong focus on accuracy.
Effective written and verbal communication skills.
Strong organizational and time management skills.
Technical proficiency in using office productivity software (e.g., Microsoft Office).
Analytical thinking and decision-making capabilities.
Ability to work independently and within a team.
Understanding of risk assessment and loss
Knowledge of insurance claim regulations and compliance requirements.

Most In-demand Soft Skills

The following list describes the most required soft skills of a Claims Analyst:

Strong interpersonal skills for building rapport and maintaining professional relationships.
Effective communication and active listening skills.
Empathy and sensitivity when dealing with policyholders during the claims process.
Excellent customer service orientation.
Ability to remain calm and composed in stressful situations.
Adaptability and flexibility to handle changing priorities and deadlines.
Strong problem-solving and decision-making abilities.
Attention to detail and a high level of accuracy in claim processing.
Analytical mindset to analyze complex claim data and identify patterns.
Collaboration and teamwork skills to work effectively with various stakeholders.

Conclusion

Claims Analysts shoulder significant responsibilities and require a combination of technical and soft skills to effectively evaluate claims, ensure compliance, and provide satisfactory outcomes for policyholders. Their role is essential in maintaining the integrity of the insurance industry and delivering exceptional customer service.