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How to Become an Insurance Claims Examiner

If you have an interest in helping others get the health care to which they’re entitled, and you have an eye for details, a job as an insurance claims examiner may be a good fit for you. An insurance claims examiner looks at health insurance claims and documentation and checks it against a patient’s health insurance policy to see whether the policy covers those health services. Also, an insurance claims examiner must also work with patients and health care providers to seek the correct documentation and answer patient questions.

Both verbal and written communication skills are essential for this role. Insurance claims examiners will not only have to speak with health care facilities and providers but also to patients and co-workers. They will have to compose denial letters if they determine the patient’s policy does not cover a particular service.

An insurance claims examiner must possess analytical skills to interpret the terms of a policy, which can often be complicated, and determine coverage. Customer service skills, especially when it comes to dealing with customer questions regarding denied claims, are also crucial for this position.

Sample job description

Insurance claims examiners are critical to the insurance industry. They are responsible for evaluating and reviewing various insurance claims and applications to ensure the due process was followed during investigations. This allows insurance adjusters’ and claimants’ work to be double-checked before any claims are approved. Insurance claims examiners need to be knowledgeable about various insurance laws to make sure legal compliance is being met and to help claims adjusters when they need it. [Your Company] is on the lookout for an experienced insurance claims examiner. We’re specifically searching for someone with great organizational skills who can pay close attention to the claims they’re looking over. If you are diligent in your work and enjoy working in insurance, we recommend that you apply to our open position as an insurance claims examiner!

Typical duties and responsibilities

  • Determine covered medical insurance losses by studying provisions of policy or certificate
  • Establish proof of loss by studying medical documentation
  • Assemble information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies
  • Initiate or investigate questionable claims
  • Document medical claims actions by completing forms, reports, logs, and records
  • Resolve medical claims by approving or denying documentation, calculate benefits due, initiate a payment, or compose a denial letter
  • Ensure legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations
  • Maintain quality customer service by following customer service practices
  • Respond to customer inquiries

Education and experience

This position requires a high school diploma or equivalent. However, a bachelor’s degree is preferred.

Required skills and qualifications

  • Understanding of health insurance administration processes
  • Strong attention to detail
  • Knowledge of medical terminology
  • Excellent interpersonal skills

Preferred qualifications

  • 4+ years of claim handling experience and demonstrated proficiency in analyzing and handling claims 
  • Excellent written and verbal communication skills

Typical work environment

Insurance claims examiners typically work for insurance carriers or the government. Insurance claims examiners usually spend their time looking over various insurance claims, however, they sometimes take over various data entry and administrative tasks. While most insurance claims examiners work full time from 9 to 5 each day, there are some opportunities to work part-time depending on the company. 

Typical hours

Many insurance claims examiners work 9 AM to 5 PM, Monday through Friday, in an office setting. However, some who work in companies that assist customers 24 hours a day could work other shifts.

Available certifications

There are several certifications available for insurance claims examiners to earn to help them succeed in their roles. Check out the following:

  • Associate in General Insurance (AINS). Earning the AINS is the perfect first step into becoming an insurance claims examiner. The course teaches the basic principles of insurance to help participants excel in their insurance roles. This includes insurance policies and regulations, life insurance planning, homeowners property coverage, insurer financial performance, and more. Earning the Associate in General Insurance will help its participants achieve their professional goals while attracting more potential employers by showing their willingness to go the extra mile to learn more! 
  • Certified Insurance Examiner (CIE). Insurance professionals are awarded the CIE if they’ve been trained in a primary field of insurance and have met the proper membership and employment requirements. Applicants must successfully earn and become an Accredited Insurance Examiner, be an IRES member, and have three years of related work experience. Since many employers don’t require a Bachelor’s degree to become an insurance claims examiner, it is extremely valuable to earn certifications like the CIE to demonstrate your expertise in the area.

Career path

Insurance claims examiners must have at least a high school diploma or GED to be hired. Some companies prefer candidates to have a bachelor’s degree or some previous work experience in the insurance or health care fields. After being hired, insurance claims examiners will usually work on smaller, routine claims under the supervision of a more experienced examiner.

Learning company policies and guidelines, as well as federal and state insurance regulations, is vital for any Insurance Claims Examiner. They must also become acquainted with customary costs of typical medical services as well as their company’s customer service policies. Insurance claims examiners can moreover pursue professional certifications such as Associate, Life and Health Claims (ALHC) or Fellow, Life and Health Claims (FLHC) from the International Claim Association to further their careers.

US, Bureau of Labor Statistics’ job outlook

SOC Code: 13-1030

2020 Employment349,400
Projected Employment in 2030340,500
Projected 2020-2030 Percentage Shift 3% decrease
Projected 2020-2030 Numeric Shift9,000 decrease

The call for more pricing transparency by health insurance companies is an important trend industry analysts are watching in the coming years. The scrutiny could likely lead to more government regulations on the health insurance industry, which means insurance claims examiners will need to stay abreast of regulatory changes and how that could affect patient coverage.

Another trend in the health insurance industry is the use of predictive analytics. Insurance companies are using big data to help high-risk customers be more proactive about their health to mitigate insurance losses later. That could lead to an influx of more health insurance claims as patients seek out preventive treatments earlier and more often, rather than wait until a significant health issue arises to seek care.