What does a Claims Examiner do?
Claims examiners review insurance claims to verify both the claimant and claim adjuster followed due process during the investigation and reporting phase of a case. Claims examiners ensure legal compliance and approve or deny insurance claims while assisting adjusters when needed. They diligently review reports to ensure that no errors have been made in the appraisal process and determine whether payout amounts are reasonable. They approve, reject, or refer a claim to a specialist and meet with claimants with dispute settlements.
Claims examiners ensure cases comply with regulatory standards, company policy, and guidelines and provide assistance to claim adjusters to manage caseloads. Claims examiners consult with specialists including lawyers or engineers and assist attorneys and other specialists when defending the company against contested claims. They contribute to the final decision coverage of losses due to an accident or illness. Claims examiners need a high school diploma for an entry-level position, and a bachelor's degree in finance or related fields is preferred.
- Efficiently investigate, evaluate, and manage all type of claims.
- Communicate with claimants, providers and vendors regarding claims issues.
- Maintain a suspense system to ensure regular review of case files.
- Prepare timely and appropriate file reviews, per departmental guidelines.
- Establish and maintain appropriate reserves in accordance with department policies and procedures.
- Input claims into the system for appropriate tracking and processing.
- Provide support, coaching and mentoring to other team members, as needed.
- Interact directly with policyholders on claim updates and resolution strategies.
- Direct and manage legal counsel to ensure timely and cost-effective litigation.
- Perform work that is varied and that may be somewhat difficult in character, but usually involves limited responsibility.
- Monitor case files daily to determine if reserves are set accurately and adjust within authority.
- Closely monitor day to day operations of self and team to ensure utilization and minimize errors.
- Accountable for reviewing adjudication software system's claim and line item edits to decide whether to pay claim/line item(s).
- Develop some level of communication with client claims managers to address issues,
- Participate in meetings and project activities outside of the primary location at locations.
- Bachelor's Degree in business or training in insurance practices and equivalent experience.
- Sound negotiation and problem solving capabilities.
- Proven record of attention to detail, time management, and leadership abilities.
- Fluent in insurance process, including negotiation, reserving, CPT Coding, and liabilities.
- Experience with HCPCS, CPT Coding, and R Language processes and software.
- Is a critical thinker and able to deploy writing protocols for correspondence including client EOB statements.
- Comfortable multitasking.
How much does a Claims Examiner make near United States?
Claims Examiner Career Path
Learn how to become a Claims Examiner, what skills and education you need to succeed, and what level of pay to expect at each step on your career path.
Years of Experience Distribution
Claims Examiner Insights
“Medical benefit package is fair to good depending on the high deductible plan you chose.”
“I worked in the call center for 5 years and my manager Ron was a great person to work for.”
“Pay is not good well not for me atleast for the years I've been here”
“Amazing group of dedicated people who really try to figure ways to get things done.”
“Work life balance is a bit off but only because there is so much work to be done.”
“Benefits are expensive and not the best for out of pocket.”
“Sedgwick is a great place to start your career but not necessarily the best place to stay for a long time.”
“You have alot of pressure and you feel unappreciated for what you do because it that.”
Claims Examiner Interviews
Frequently asked questions about the roles and responsibilities of a Claims Examiner
- Claims Analyst
- Claims Adjuster
- Claims Representative
- Claims Manager