Claims Examiner Job Description [Updated for 2025]

In the field of insurance, the focus on claims examiners has never been sharper.

As the industry continues to evolve, so does the demand for skilled professionals who can accurately assess, process, and manage insurance claims.

But let’s delve deeper: What’s truly expected from a claims examiner?

Whether you are:

• A job seeker trying to understand the core of this role,
• A hiring manager outlining the perfect candidate,
• Or simply interested in the inner workings of claims examination,

You’re in the right place.

Today, we present a customizable claims examiner job description template, designed for seamless posting on job boards or career sites.

Let’s dive straight into it.

Claims Examiner Duties and Responsibilities

Claims Examiners are responsible for reviewing insurance claims and determining whether those claims are valid and how much the insurance company should pay.

They play a critical role in the insurance industry by ensuring claims are processed accurately and efficiently.

Their duties and responsibilities include:

• Review and examine insurance claims for accuracy, completeness, and eligibility
• Analyze information in insurance claims to determine the extent of the insurance company’s liability
• Investigate questionable claims
• Communicate with claimants, insurance agents, and other involved parties to gather more information and coordinate claim resolution
• Make recommendations for claim approval or denial or referral to investigators
• Consult with legal counsel on claims when necessary
• Authorize payments or refer claim to a more senior examiner or investigator
• Maintain claim files and follow up to ensure resolution
• Stay updated on industry regulations, trends, and policy changes
• Compile, analyze, and report data on claims

 

Claims Examiner Job Description Template

Job Brief

We are searching for a detail-oriented and experienced Claims Examiner to manage and review insurance claims.

As a Claims Examiner, your duties will include investigating and processing insurance claims, negotiating settlements, and maintaining accurate records of claims.

The ideal candidate should have a strong understanding of insurance policies and regulations, excellent investigative skills, and exceptional customer service skills.

 

Responsibilities

• Review and validate insurance claims for accuracy and completeness.
• Examine claim forms, policies, and endorsements to determine coverage.
• Investigate and document claims using applicable software and databases.
• Negotiate settlements in accordance with company policies and procedures.
• Work closely with claimants to get additional information regarding claims.
• Communicate with legal counsel on claims requiring litigation.
• Keep accurate records of claims, settlements, and denials.
• Provide excellent customer service to claimants.
• Stay updated on insurance regulations, statutes, and best practices.
• Coordinate with insurance adjusters, medical professionals, and investigators as necessary.

 

Qualifications

• Proven work experience as a Claims Examiner or similar role in insurance.
• Knowledge of insurance policies and regulations.
• Strong investigative and analytical skills.
• Excellent communication and customer service skills.
• Ability to manage multiple claims and tasks efficiently.
• Proficient in MS Office and insurance related software.
• Bachelor’s degree in Business, Insurance, or related field preferred.

 

Benefits

• 401(k) plan
• Health insurance
• Dental insurance
• Life insurance
• Paid time off
• Professional development opportunities

 

Additional Information

• Job Title: Claims Examiner
• Work Environment: Office setting with options for remote work. Some travel may be required for investigations or consultations.
• Reporting Structure: Reports to the Claims Manager or Director of Claims.
• Salary: Salary is based upon candidate experience and qualifications, as well as market and business considerations.
• Pay Range: $48,000 minimum to $78,000 maximum
• Location: [City, State] (specify the location or indicate if remote)
• Employment Type: Full-time
• Equal Opportunity Statement: We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
• Application Instructions: Please submit your resume and a cover letter outlining your qualifications and experience to [email address or application portal].

 

What Does a Claims Examiner Do?

Claims Examiners work primarily in the insurance industry where they analyze and investigate insurance claims to determine the extent of the insuring company’s liability.

Their main role is to review insurance claims that have been filed by policyholders, to verify if the claims are valid or not.

They do this by evaluating insurance policies to understand coverage limits and exclusions, and by investigating the circumstances and details of each claim.

They work closely with adjusters, appraisers, and medical experts to gather more information on each claim.

This could include reviewing medical records or police reports, or inspecting property damage.

Claims Examiners may also be responsible for negotiating settlements with claimants and their attorneys.

They decide on the amount to be paid on a claim and authorize the payment.

They are also involved in denying a claim or referring a suspect claim to investigators for further scrutiny if there’s any suspicion of insurance fraud.

The objective of a Claims Examiner is to ensure that all claims are handled fairly and that the insurance company pays out only what it is legally obligated to under the terms of the policy.

 

Claims Examiner Qualifications and Skills

Claims Examiners need a blend of technical knowledge, analytical ability, and excellent communication skills to effectively process and investigate insurance claims, including:

• Understanding of insurance policies, practices, and procedures to accurately assess various types of claims.
• Strong analytical skills to determine the validity of a claim by examining documents, medical records, and other evidence.
• Excellent attention to detail to ensure all information is accurate, complete, and conforms to policy and legal requirements.
• Effective communication skills to relay claim decisions to claimants, discuss cases with legal counsel, and liaise with other professionals involved in the claim process.
• Good negotiation skills to settle claims fairly and expediently, often involving negotiations with claimants or their representatives.
• Problem-solving abilities to identify and resolve potential complications or disputes related to claims.
• Time management skills to process claims in a timely and efficient manner, especially in high-volume or high-pressure situations.
• Proficiency in using claims management software to enter and track claim data, generate reports, and maintain claim files.

 

Claims Examiner Experience Requirements

Claims Examiners often start with a degree in business or a related field, although some companies may hire those with a high school diploma and relevant experience.

Entry-level candidates typically need at least 1 to 2 years of experience in insurance, risk management, or a related field.

This experience can often be gained through internships, part-time roles, or trainee positions in insurance companies or related industries.

Candidates with 3 or more years of experience usually have a solid foundation in processing insurance claims, interpreting insurance policies, and negotiating settlements.

They may have gained this experience in roles such as Claims Assistant, Claims Analyst, or Insurance Adjuster.

Those with more than 5 years of experience are often well-versed in managing complex or high-value claims and may have some supervisory or managerial experience.

They may be ready for senior Claims Examiner positions or roles involving team leadership or claims department management.

Additionally, some roles may require specific certification, such as the Associate in Claims (AIC) or Certified Professional in Insurance & Risk Management (CPIRM), which can be obtained through additional training and experience in the field.

 

Claims Examiner Education and Training Requirements

Claims Examiners typically require a bachelor’s degree, often in fields such as business administration, insurance, or a related discipline.

Practical skills in areas such as insurance law, business, and economics are commonly emphasized in these degree programs.

While not always a requirement, some employers may prefer candidates with a professional certification, such as the Associate in Claims (AIC) or Certified Claims Professional (CCP) designation.

These certifications, provided by organizations such as the Insurance Institute of America and The Society of Claim Law Associates, require successful completion of specific coursework and examinations.

A strong foundation in computer skills, particularly database management and word processing, is typically expected as claims examiners spend a significant amount of time entering data and writing reports.

Most states require claims examiners to obtain a license to practice, which involves passing a state-administered examination after meeting the education and experience requirements.

On-the-job training is also common in this profession, with new hires often working under the supervision of more experienced claims examiners.

As with many professions, continuing education is important for claims examiners, who must stay updated on changes in insurance laws and policies.

 

Claims Examiner Salary Expectations

A Claims Examiner can expect to earn an average salary of $64,690 (USD) per year.

However, the actual salary may differ based on factors such as the level of experience, qualifications, location, and the insurance company they work for.

 

Claims Examiner Job Description FAQs

What are the key skills required for a Claims Examiner?

Claims Examiners need to have strong analytical skills to assess the validity of claims and determine the appropriate payment.

They should also possess good interpersonal and communication skills to interact with claimants, witnesses, and insurance agents.

Attention to detail is crucial for reviewing documents and determining the accuracy of the claims.

 

What is the difference between a Claims Examiner and a Claims Adjuster?

While both roles handle insurance claims, a Claims Examiner generally works in an office reviewing claims that have been submitted, whereas a Claims Adjuster often travels to the site of an incident to conduct an investigation.

A Claims Examiner makes the final decision on the approval or denial of a claim, while a Claims Adjuster is responsible for assessing the damage and estimating the cost of a claim.

 

Do Claims Examiners need specific qualifications?

While a high school diploma is the minimum requirement, some employers prefer candidates with a bachelor’s degree.

Additionally, Claims Examiners often need to have prior experience in the insurance industry.

There are also certain certifications and licenses that may be required or beneficial, such as the Claims Law Associate designation.

 

What duties does a Claims Examiner typically perform?

Claims Examiners review insurance claims for validity, determining whether the policy covers the loss claimed.

They often consult with medical specialists, investigators, or legal counsel to help assess claims.

They may also negotiate settlements and authorize payments, as well as communicate with claimants about claim details and decisions.

 

What qualities make a good Claims Examiner?

A good Claims Examiner is detail-oriented, being able to meticulously review and assess claims.

They also have strong communication skills, enabling them to effectively interact with various parties involved in the claims process.

Additionally, they should be able to handle stressful situations and make sound decisions under pressure.

Good Claims Examiners also have a solid understanding of insurance policies and regulations.

 

Conclusion

And there you have it.

Today, we’ve delved deep into the multifaceted role of a claims examiner.

Surprising, right?

It’s not just about evaluating insurance claims.

It’s about forging a secure future, one claim at a time.

With our handy claims examiner job description template and real-life instances, you’re ready to step up.

But why limit yourself?

Take the plunge with our job description generator. It’s your essential tool for creating detailed job listings or refining your resume to perfection.

Remember:

Every claim examined is a step towards a more protected world.

Let’s create that security. Together.

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