Health Insurance Claims Examiner Job Description [Updated for 2025]

In today’s healthcare landscape, the importance of health insurance claims examiners is more crucial than ever.

As healthcare complexities and insurance intricacies evolve, the demand for skilled professionals who can efficiently process, scrutinize, and manage insurance claims continues to grow.

But let’s delve deeper: What’s genuinely expected from a health insurance claims examiner?

Whether you are:

• A job seeker eager to understand the core of this role,
• A hiring manager outlining the perfect candidate,
• Or simply fascinated by the intricate process of health insurance claims examination,

You’re in the right place.

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

Let’s dive right into it.

Health Insurance Claims Examiner Duties and Responsibilities

Health Insurance Claims Examiners play a critical role in the healthcare system, reviewing and investigating insurance claims to determine the extent of an insurance company’s liability.

They help ensure fair and accurate compensation based on an individual’s insurance policy.

Their main duties and responsibilities include:

• Evaluating and investigating insurance claims to determine the validity
• Interpreting the policy terms to establish the company’s potential liability
• Communicating with claimants, medical professionals, and legal experts to gather more information about claims
• Calculating benefit payments based on claimant’s policy coverage
• Ensuring the prompt processing and payment of valid claims
• Denying or reducing the payment of invalid or excessive claims
• Compiling reports detailing claim trends and costs for management review
• Complying with federal and state regulations in all aspects of claim handling
• Assisting in fraud detection by alerting supervisors of suspicious claims

 

Health Insurance Claims Examiner Job Description Template

Job Brief

We are seeking a meticulous and dedicated Health Insurance Claims Examiner to join our team.

Your role will involve reviewing health insurance claims, verifying the validity of the information, coordinating with healthcare providers and claimants, and ensuring the accurate and timely processing of claims.

Our ideal candidate will have a firm grasp of health insurance policies, medical terminology, and legal aspects of health insurance.

Excellent analytical, communication, and negotiation skills are key to success in this role.

 

Responsibilities

• Review and examine health insurance claims for accuracy and completeness
• Coordinate with healthcare providers and claimants to obtain missing information
• Determine the validity of insurance claims by verifying documentation and liaising with medical experts
• Ensure that insurance claims are processed in a timely and accurate manner
• Interpret medical and policy terminology and determine eligibility of claims based on the policy
• Handle any inquiries, concerns, or disputes related to insurance claims
• Maintain accurate and up-to-date claim records
• Perform negotiations with claimants or their representatives when necessary

 

Qualifications

• Proven work experience as a Health Insurance Claims Examiner or similar role
• Knowledge of health insurance processes, medical terminology, and related laws and regulations
• Strong analytical and problem-solving skills
• Excellent verbal and written communication skills
• Detail-oriented with a high level of accuracy
• Able to work independently and make sound judgments
• High school diploma required; Bachelor’s degree in a related field preferred

 

Benefits

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

 

Additional Information

• Job Title: Health Insurance Claims Examiner
• Work Environment: Office setting. Some travel may be required for training and professional development purposes.
• Reporting Structure: Reports to the Claims Department Manager.
• Salary: Salary is based upon candidate experience and qualifications, as well as market and business considerations.
• Pay Range: $45,000 minimum to $75,000 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 Health Insurance Claims Examiner Do?

Health Insurance Claims Examiners primarily work in the insurance industry, particularly in health-related insurance companies.

They can work in insurance firms, hospitals, or medical facilities that provide health coverage to their employees.

Their main role is to analyze and process insurance claims submitted by policyholders or medical providers.

They review claims to verify their accuracy, ensure that the treatments or services provided are covered under the policy, and determine the appropriate payment amount.

Claims Examiners also work closely with medical professionals to verify the legitimacy of the claim, seeking additional information when necessary.

They may need to contact policyholders or medical providers to clarify information or to request additional documentation.

They play a crucial role in fraud detection, as they must identify any irregularities or discrepancies in the claims.

Claims Examiners also communicate with claimants regarding the status of their claims, explaining the reasons for denial or delays when necessary.

In some cases, Claims Examiners may negotiate with healthcare providers over disputed claims or fees.

Their ultimate goal is to ensure that legitimate claims are paid correctly and promptly, while protecting the company from fraudulent or inflated claims.

 

Health Insurance Claims Examiner Qualifications and Skills

A Health Insurance Claims Examiner should possess a mix of industry-specific knowledge, technical skills, and soft skills to efficiently process and review insurance claims, such as:

• Strong knowledge of medical terminology, coding, and health insurance policies to accurately interpret and evaluate insurance claims.
• Exceptional attention to detail and analytical skills to review the accuracy of all information provided in insurance claims.
• Excellent communication skills to liaise with medical professionals and policyholders, clarify claim details, and relay claim decisions.
• Good decision-making abilities to determine the legitimacy of a claim and make fair and accurate claim settlements.
• Proficiency in using computer software and systems for data entry, claim processing, and record-keeping.
• Effective time management skills to handle multiple claims simultaneously and meet strict deadlines.
• Interpersonal skills to work collaboratively with other insurance professionals and provide excellent service to policyholders.
• Problem-solving skills to address and resolve any issues that may arise during the claim process.

 

Health Insurance Claims Examiner Experience Requirements

Candidates for a Health Insurance Claims Examiner role typically need to have at least 1 to 2 years of experience in the field of health insurance, ideally in a role that involves claims processing or a closely related function.

This can be obtained through full-time work, an internship, or a part-time position.

Experience in medical coding or knowledge about medical terminology can be beneficial.

Proficiency in using claims processing software and familiarity with the Health Insurance Portability and Accountability Act (HIPAA) regulations is generally expected.

Candidates with 3 to 5 years of experience might have had exposure to more complex claims and case management.

They may also have experience in a supervisory role, training new examiners, or managing a small team.

Those with over 5 years of experience often possess a deep understanding of healthcare laws, regulations, and policies.

They may have taken on leadership roles, have been involved in policy development or strategic planning, and are usually ready to take on senior or managerial positions.

Additionally, obtaining a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification can increase job prospects and advancement opportunities.

 

Health Insurance Claims Examiner Education and Training Requirements

Health Insurance Claims Examiners typically have a high school diploma or equivalent education.

Many employers prefer candidates with an associate’s degree or bachelor’s degree in health information technology, health management, or related field.

Fundamental knowledge in medical terminology, billing and coding procedures, and health insurance policies is required.

As such, many Health Insurance Claims Examiners pursue certifications in these areas.

Experience in the health insurance industry is often required, with preference given to those who have had specific exposure to claims examining and processing.

On-the-job training is typically provided to new hires.

This allows them to understand specific procedures and software used by the company, and to become familiar with company policies and guidelines.

Furthermore, Claims Examiners need to be aware of constantly changing healthcare regulations, thus continuous learning and staying updated is vital in this role.

As this position involves dealing with detailed documents and sensitive information, strong analytical skills, attention to detail, as well as understanding and adhering to privacy regulations, are key to success as a Health Insurance Claims Examiner.

 

Health Insurance Claims Examiner Salary Expectations

A Health Insurance Claims Examiner can expect to earn an average salary of $64,890 (USD) per year.

The actual salary may differ based on factors such as experience, qualifications, location, and the company that they work for.

 

Health Insurance Claims Examiner Job Description FAQs

What skills does a Health Insurance Claims Examiner need?

A Health Insurance Claims Examiner should have excellent analytical skills to evaluate the legitimacy of a claim and determine the proper payout.

They should have a strong knowledge of health insurance policies, regulations, and procedures.

Good communication skills are also essential, as they often have to liaise with insurance agents, medical personnel, and claimants.

Attention to detail and organizational skills are also vital in dealing with large amounts of data and paperwork.

 

Do Health Insurance Claims Examiners need a degree?

While not always required, many employers prefer Health Insurance Claims Examiners to have a bachelor’s degree in business, economics, or a related field.

Some companies may also favor candidates with a background in nursing or healthcare to better understand medical terminology and procedures.

However, significant experience in insurance or healthcare may sometimes substitute for educational requirements.

 

What should you look for in a Health Insurance Claims Examiner resume?

In a Health Insurance Claims Examiner’s resume, look for a strong background in the insurance industry, particularly in claims examination.

Relevant experience in healthcare can also be a significant advantage.

Verify whether the candidate has handled complex claims and has experience with claim investigation.

Key skills to look for include analytical thinking, attention to detail, knowledge of insurance regulations, and understanding of medical terminology.

 

What qualities make a good Health Insurance Claims Examiner?

A good Health Insurance Claims Examiner is meticulous, detail-oriented, and has a strong sense of fairness.

They need to be decisive, as they often need to make judgments on whether a claim is legitimate or not.

Good communication skills are essential for interacting with claimants, healthcare providers, and insurance personnel.

They should also be patient and compassionate, as they often deal with individuals facing health crises.

 

What is the career progression for a Health Insurance Claims Examiner?

With experience, a Health Insurance Claims Examiner could advance to a supervisory or managerial role, overseeing other examiners and claims processes.

They may also specialize in complex or high-value claims.

Some may transition into other areas of insurance, such as underwriting or policy development.

Continuing education and professional certifications can enhance career prospects.

 

Conclusion

There you have it.

Today, we’ve unraveled the mysteries of what it truly means to be a health insurance claims examiner.

And guess what?

It’s not just about processing claims.

It’s about ensuring accurate and fair reimbursement, one claim at a time.

With our comprehensive health insurance claims examiner job description template and real-world examples, you’re all prepared to take the next step.

But why stop there?

Go further with our job description generator. It’s your key to creating razor-sharp job listings or fine-tuning your resume to absolute perfection.

Remember:

Every processed claim is a step towards better healthcare.

Let’s take those steps. Together.

How to Become a Health Insurance Claims Examiner (Complete Guide)

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