Claims Examiner Job Description

Claims Examiner Job Description

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Claims examiner provides and maintain exceptional customer service and ongoing communication to the appropriate stakeholders through the life of the claim including prompt contact and follow up to complete timely and accurate investigation, damage evaluation and claim resolution in accordance with regulatory, company standards, and authority level.

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:

Complete company training program
Claims will be processed within established policy, company and client guidelines and must be reviewed, based on authority level, by the Claims Supervisor and/or Director prior to payment
Process claims using various in-house external systems
Work independently within a team environment
Analyzes professional and/or hospital claims for accuracy according to set dollar thresholds, and meets and maintains production and quality standards
Reviews authorization and/or provider's contract and adjudicates claims accordingly
Perform any correspondence, follow-up and any projects delegated by claims supervisor
Primarily responsible for Mobile Home, Dwelling (including Condo Unit) and Small Commercial Claims
Determines whether and when Expert required
Reviews System work queues, promptly enters or updates data into System

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:

Medical terminology
ICD-9
CPT
Recoveries offsets and deductions
Appropriate insurance principles and laws for line of business handled
Claim and disability duration
MS Office
HMO
Medicaid
HCPC

Desired experience for claims examiner includes:

Knowledge of PC applications and systems
Ability to read and interpret general business correspondence, procedure manuals, and specific plan documents
Ability to perform basic math functions – addition, subtraction, multiplication, and division
Provide professional assistance to adjusters, law enforcement, attorneys, that are involved in incidents where there exists potential liability and claims against the Company
Maintain a suspense system to ensure regular review of case files
Conduct initial and follow up contact and/or correspondence with claimants, insurance companies, attorneys, regarding claim submission

Claims Examiner Examples

1

Claims Examiner Job Description

Job Description Example
Our innovative and growing company is hiring for a claims examiner. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims examiner
  • 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
Qualifications for claims examiner
  • 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
2

Claims Examiner Job Description

Job Description Example
Our company is hiring for a claims examiner. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims examiner
  • 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
Qualifications for claims examiner
  • 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
3

Claims Examiner Job Description

Job Description Example
Our company is searching for experienced candidates for the position of claims examiner. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims examiner
  • 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
Qualifications for claims examiner
  • 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
4

Claims Examiner Job Description

Job Description Example
Our company is searching for experienced candidates for the position of claims 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 claims examiner
  • 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
Qualifications for claims examiner
  • 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
5

Claims Examiner Job Description

Job Description Example
Our company is searching for experienced candidates for the position of claims examiner. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for claims examiner
  • 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
Qualifications for claims examiner
  • 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

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