Insurance Claims Examiner Job Description [Updated for 2025]

In the constantly evolving world of insurance, the role of claims examiners has become more critical than ever.

As the industry advances, there is a growing demand for skilled professionals who can meticulously assess, validate, and manage insurance claims.

But what exactly does an insurance claims examiner do?

Whether you are:

• A job seeker trying to understand the core responsibilities of this role,
• A hiring manager outlining the qualities of an ideal candidate,
• Or simply curious about the intricacies of insurance claims examination,

You’re in the right place.

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

Let’s delve into it.

Insurance Claims Examiner Duties and Responsibilities

Insurance Claims Examiners play a crucial role in the insurance industry by ensuring the fair and accurate settlement of insurance claims.

They assess and investigate insurance claims to determine the extent of the insuring company’s liability.

Their duties and responsibilities include:

• Review and evaluate insurance claims to determine if they are covered under a policy
• Analyze information presented on insurance claims forms, policies, and documentation provided by claimants
• Investigate and research details of the claim, which may include talking to claimants, witnesses, and healthcare professionals
• Coordinate with insurance adjusters to gather additional information, if necessary
• Make decisions on the validity of a claim and approve or deny payment
• Determine the appropriate amount of payout on approved claims
• Consult with legal counsel on claims when necessary
• Identify potential fraudulent claims and refer them to investigators
• Keep track of claims, settlements, denials, and any other relevant claim information
• Stay updated with current legislation and regulations that impact insurance claims

 

Insurance Claims Examiner Job Description Template

Job Brief

We are looking for a meticulous Insurance Claims Examiner to investigate and process insurance claims.

The Insurance Claims Examiner will be responsible for reviewing the claim, collecting necessary information, determining the validity of the claim and authorizing payments or denials.

Our ideal candidate has a solid understanding of insurance contracts, policy interpretation and claims processing.

They should be detail-oriented, have excellent problem-solving skills, and be able to work independently.

 

Responsibilities

• Review and evaluate insurance claims for accuracy and validity
• Collect necessary information to process the claim, including medical records and police reports
• Interpret policy to determine coverage
• Authorize payments or refer claims to investigators for further review
• Communicate with claimants, medical professionals, and legal counsel to gather more information
• Maintain accurate records of claims and policies
• Provide recommendations for claim resolution
• Comply with legal and company regulations and procedures

 

Qualifications

• Proven work experience as an Insurance Claims Examiner or similar role
• Excellent understanding of insurance contracts, policy interpretation and claims processing
• Strong analytical and problem-solving skills
• Excellent communication and negotiation skills
• Ability to work independently and maintain high level of accuracy
• BSc degree in Business Administration, Finance or relevant field
• Insurance certification (e.g. Associate in Claims) is a plus

 

Benefits

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

 

Additional Information

• Job Title: Insurance Claims Examiner
• Work Environment: Office setting with potential for remote work. Some travel may be required for investigations and client meetings.
• Reporting Structure: Reports to the Claims Supervisor or Claims Manager.
• Salary: Salary is based upon candidate experience and qualifications, as well as market and business considerations.
• Pay Range: $56,000 minimum to $92,000 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 an Insurance Claims Examiner Do?

Insurance Claims Examiners typically work for insurance companies across various industries including auto, health, life, and property insurance.

They review and investigate insurance claims filed by policyholders to determine the validity of the claim.

This process involves analyzing and interpreting the insurance policy, assessing the damage or loss claimed, and determining if the claim is covered under the policyholder’s insurance plan.

Insurance Claims Examiners also negotiate settlements with the claimant or their legal representative.

They may need to consult with other professionals such as medical experts, legal advisors, and loss adjusters to gain a full understanding of the claim.

In cases of suspected fraud, they gather evidence, interview claimants and witnesses, and work closely with investigators or law enforcement officials.

Their main goal is to ensure that valid claims are paid out in a timely manner and fraudulent claims are denied, thereby protecting the financial interests of the insurance company.

They are also responsible for maintaining accurate records of all claims, and may need to prepare reports outlining their findings and decisions.

They often communicate with policyholders to provide updates on the progress of their claim, and to explain the company’s decision regarding the claim.

 

Insurance Claims Examiner Qualifications and Skills

Insurance Claims Examiners require a mix of industry knowledge, soft skills and technical abilities to analyze and settle insurance claims efficiently, including:

• Strong analytical skills to interpret complex documents, recognize discrepancies in data, and determine coverage based on policy conditions
• Excellent attention to detail to ensure all information in a claim is accurate and complete and that all necessary documents have been provided
• Effective communication and interpersonal skills to liaise with claimants, insurance agents and other professionals involved in the claim process
• Knowledge of insurance laws, regulations and procedures to ensure claims are handled appropriately and legally
• Good negotiation skills to settle claims fairly and cost-effectively
• Problem-solving skills to identify solutions in cases where claims are contested or complicated
• Ability to manage time effectively, prioritizing tasks to handle multiple claims simultaneously and meet deadlines
• Experience with claims software and other related computer applications for data management and record keeping

 

Insurance Claims Examiner Experience Requirements

Entry-level candidates for the role of an Insurance Claims Examiner typically have 1 to 2 years of experience in the insurance industry, often gained through internships or part-time roles.

This could be in roles such as Claims Assistant, Claims Analyst, or other insurance-related positions.

To effectively execute their responsibilities, these professionals need to have prior experience in evaluating insurance claims, understanding insurance policies, and dealing with claimants and adjusters.

Having a background in customer service or law can also be helpful.

Candidates with more than 3 years of experience often have comprehensive knowledge about insurance contracts and regulations, experience in investigating and settling claims, and strong negotiation skills, which are honed in roles like Claims Specialist or Claims Adjuster.

Insurance Claims Examiners with over 5 years of experience are usually well-versed in handling complex or high-value claims and may have led teams or trained junior staff members.

This makes them suitable for senior roles or leadership positions within the claims department.

Some employers may also require these experienced candidates to possess certifications like the Associate in Claims (AIC) or Chartered Property Casualty Underwriter (CPCU).

 

Insurance Claims Examiner Education and Training Requirements

Insurance Claims Examiners typically require a bachelor’s degree in business, finance, insurance, or a related field.

It is important for the candidates to have strong analytical, problem-solving, and communication skills to evaluate insurance claims accurately and negotiate settlements effectively.

While not always mandatory, several employers prefer candidates with relevant work experience in insurance or claims management.

For this reason, internships during the academic years could be beneficial.

Most states require licensure for Insurance Claims Examiners.

The requirements for licensure usually include completing pre-licensure education and passing a state-administered exam.

The specific requirements may vary from state to state.

Professional certification, like those offered by The Institutes Risk and Insurance Knowledge Group, can enhance job prospects.

These certifications demonstrate a candidate’s expertise in various types of insurance and claims handling.

Some Insurance Claims Examiners may also choose to pursue a master’s degree in insurance management or a related field to advance in their careers.

This might be particularly useful for those who aim to take up managerial or leadership roles.

Continuing education is also crucial in this field due to the ever-changing laws and regulations related to insurance.

Many companies offer training sessions and workshops to help their employees stay updated.

 

Insurance Claims Examiner Salary Expectations

An Insurance Claims Examiner earns an average salary of $64,890 (USD) per year.

The actual earnings can fluctuate based on factors such as experience, specializations, geographical location, and the company for which they work.

 

Insurance Claims Examiner Job Description FAQs

What skills does an Insurance Claims Examiner need?

Insurance Claims Examiners need strong analytical skills to assess insurance claims thoroughly and decide the validity of the claim.

They must possess excellent communication and negotiation skills to interact with claimants, witnesses, and insurance agents.

They should also have a solid understanding of insurance policies and legalities surrounding claims.

 

Do Insurance Claims Examiners need a degree?

Insurance Claims Examiners usually need a bachelor’s degree, commonly in fields such as business or finance.

Some employers might require a specific degree in insurance or a related field.

Apart from the educational qualifications, many insurance companies provide on-the-job training.

 

What should you look for in an Insurance Claims Examiner resume?

An Insurance Claims Examiner’s resume should highlight their analytical skills and attention to detail, as these are key in examining insurance claims.

Any relevant experience in the insurance industry, especially in the field of claims handling, is beneficial.

Their education details, including a bachelor’s degree in a relevant field, should also be checked.

Certifications such as Associate in Claims (AIC) can be a plus.

 

What qualities make a good Insurance Claims Examiner?

A good Insurance Claims Examiner is detail-oriented and can pinpoint inconsistencies in claims documents.

They have excellent communication skills to relay information effectively to all parties involved.

They should be able to work independently and make decisions objectively based on the facts of each case.

It’s also important for them to be empathetic and patient, as they often deal with claimants who may be experiencing distress.

 

Is it difficult to hire Insurance Claims Examiners?

Hiring Insurance Claims Examiners can be challenging due to the specific skill set required, such as strong analytical abilities and a deep understanding of insurance policies.

However, attracting the right candidates can be achieved by offering a competitive salary, opportunities for career advancement, and ongoing training and development opportunities.

 

Conclusion

And there you have it.

Today, we’ve uncovered the true essence of being an insurance claims examiner.

Surprised?

It’s not just about reviewing insurance claims.

It’s about safeguarding financial stability, one claim at a time.

With our trusty insurance claims examiner job description template and real-world examples, you’re ready to embark on this career journey.

But why halt your progress here?

Explore further with our job description generator. It’s your invaluable tool for creating razor-sharp job listings or perfecting your resume.

Always remember:

Every claim you examine is a part of a larger financial safeguarding mechanism.

Let’s secure that future. Together.

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