Claim Examiner Job Description
Claim examiner
provides clinical expertise in the application of medical and reimbursement policies within the claim adjudication process through claim review, medical record review and research.
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:
Conducts and controls investigations on contestable and accident claims on policies with face amounts under $10,000 and claims for disability premium waiver
The examiner will ensure that all claims are managed to the highest standard, whether by external TPA or internal staff, eliminating unnecessary payments and minimizing the costs of handling claims
Reviews their own and other associates’ paid claims for accuracy and completeness
Manages all aspects of investigative activity on complex claims
Recognize and identify potential fraudulent claims
Establish reserves, using independent judgment and expertise and authorizes payments within scope of authority, settling claims, ensuring timely issuance of disbursements
Proper use and direction of TPA personnel and oversight of their claims management practices
Ensure the claims assigned to this examiner are adequately reserved at all times, that reserves are adjusted timely and appropriately based on the current support in the claim file, and that appropriate documentation that speaks to the value of the case has been or is being requested by the file handler
The examiner will assist the locations in submitting information necessary to take liability or subrogation claims forward
Ability to evaluate, negotiate and settle claims with high dollar exposure
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:
Claims
Claim adjudication and benefit plan application for Texas Medicaid
Excel
Medical benefits and medical terminology
Medical claim processing procedures and guidelines
Medical terminology
Breadth and /
Contract provisions and tax ramifications
Covered benefits
Depth within Professional Liability claims
Desired experience for claim examiner includes:
Calculates reimbursement of benefits according to the schedule of coverage
Responsible for completing project work as assigned by management
Some college work preferred
Must have Florida Workers' Compensation License
Workers Compensation (WC) Adjuster
Promptly and appropriately develop the file to provide accurate and timely investigation and loss analysis
Claim Examiner Examples
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Claim Examiner Job Description
Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of claim examiner. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for claim examiner
- 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
Qualifications for claim examiner
- 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
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Claim Examiner Job Description
Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of claim examiner. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claim examiner
- 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
Qualifications for claim examiner
- 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
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Claim Examiner Job Description
Job Description Example
Our innovative and growing company is looking for a claim examiner. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for claim examiner
- 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
Qualifications for claim examiner
- 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
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Claim Examiner Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of claim examiner. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claim examiner
- 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
Qualifications for claim examiner
- 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
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Claim Examiner Job Description
Job Description Example
Our growing company is looking for a claim examiner. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claim examiner
- 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
Qualifications for claim examiner
- 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