What is an insurance claims examiner?
An insurance claims examiner is a professional who investigates insurance claims to determine the extent of an insurance company’s liability. They compare the claimant’s account of the incident with the details documented in the policy to confirm accuracy and fairness. The primary purpose of this role is to protect the insurance company’s financial health by rigorously examining claims to avoid fraudulent cases or excessive payouts. The examiner plays a pivotal role in balancing the interests of policyholders and the insurance company, ensuring claim settlements are conducted accurately, promptly, and fairly.
Duties and responsibilities
An insurance claims examiner is responsible for reviewing insurance claims after they are submitted, which involves assessing the validity of the claim and confirming all necessary documents are provided, such as medical reports or police statements, in the case of health or auto insurance, respectively. The examiner must also evaluate whether the policy covers the claimed incident. If the claim is valid, they must determine the appropriate payment amount based on the policy’s terms. In some instances, they contact claimants, medical professionals, or law enforcement officers for additional details. The examiner also collaborates closely with insurance adjusters and underwriters throughout the claim investigation process.
The work environment for an insurance claims examiner is typically in an office within an insurance company. They spend significant time reviewing documents and conducting research on a computer, which can be sedentary. However, depending on the type of insurance, they may have to occasionally visit the site of an accident or property that’s been damaged and interview witnesses and claimants. In such instances, the job might involve travel and outdoor work, including investigation scenes that may be stressful or unpleasant. An examiner must be comfortable with both desk work and the potential for field investigations.
Typical work hours
Typically, an insurance claims examiner works full-time, with regular business hours from Monday to Friday. Depending on the workload and the urgency of certain claims, overtime may occasionally be necessary, especially in periods following natural disasters or significant events triggering a large number of claims. As with many professions, the digitalization of the industry could offer remote work opportunities or flexible work arrangements.
How to become an insurance claims examiner
In order to become an insurance claims examiner, you will need a combination of education, certification, and experience. In this career guide section, we cover the steps you’ll need to take to achieve your goal:
Step 1: Obtain a high school diploma
The minimum educational requirement is a high school diploma or equivalent GED certificate. This stage of education provides the necessary foundational skills for further studies, including communication, mathematics, and critical thinking abilities.
Step 2: Pursue a bachelor’s degree (optional)
While a bachelor’s degree isn’t always required, many employers prefer candidates who have one. Relevant fields of study include business administration, finance, and economics. These programs offer subject matter that helps in understanding insurance operations and financial aspects.
Step 3: Gain initial work experience
Before becoming an examiner, it’s common to gain work experience in related insurance jobs – in roles like claims adjuster or underwriter. This experience allows you to familiarize yourself with the claims investigation and evaluation process.
Step 4: Obtain industry certifications
Earning professional certifications can greatly enhance your career prospects. Consider pursuing the Certified Claims Professional (CCP) or Associate in Claims (AIC), as these programs offer advanced knowledge of claims management and demonstrate your commitment to the profession.
Step 5: Continue learning through professional development
The insurance industry is continually evolving, with constant changes to rules, regulations, and best practices. Keeping up with these changes through continued learning via seminars, conferences, and courses can increase your effectiveness in the role and enhance your career prospects.
Step 6: Apply for jobs
Once you’ve obtained the necessary education, experience, and certification, you can start applying for jobs as an insurance claims examiner. Craft a well-formatted resume highlighting your education, certification, experience, and key skills relevant to the role. It’s also beneficial to prepare for common interview questions to help increase your chances of landing a job.
How much do insurance claims examiners make?
Insurance claims examiner salaries will vary based on experience, industry, education, location, and organization size. Certification can lead to a higher salary, as well as expertise in specialized areas of claims investigation.
Highest paying industries
- Government – $68,300
- Hospitals – $63,700
- Insurance Carriers – $62,980
- Brokerage Agencies – $60,450
- Insurance Claims Adjustment Companies – $58,500
Highest paying states
- Connecticut – $72,980
- New Jersey – $70,120
- New York – $69,540
- Massachusetts – $67,680
- California – $66,500
Types of insurance claims examiners
Below, we explore common career types and areas of specialization for insurance claims examiners. In this section, you will gain insights about various roles and duties, which usually differ based on the type of insurance, such as health, life, auto, or home insurance.
Health insurance claims examiner
One specialization within the insurance claims examiner field is health insurance. Professionals in this role are responsible for reviewing medical claims to verify the claim’s validity and determine the appropriate payout. This usually requires a good understanding of medical terminology and procedures and a comprehensive knowledge of healthcare laws and regulations.
Life insurance claims examiner
Concentrating on life insurance, these examiners undergo similar duties as other insurance claims examiners but work specifically with life insurance policies. They must read and decipher complex life insurance policies and make decisions on the validity of a claim based on those policy specifics. Often, this involves investigating deaths to verify information provided in the claim.
Auto insurance claims examiner
Specializing in motor insurance, these professionals evaluate auto insurance claims. They may inspect vehicle damage, check police reports, and interview claimants and witnesses to assess the extent of liability. They ensure that payout amounts are fair, accurate, and within policy limits.
Home insurance claims examiner
Those focusing on home insurance claims often assess property damage following fires, floods, or thefts. Their responsibilities may also involve assessing the extent of damage or loss, determining whether the claim is covered under the policy, and arriving at fair and accurate settlement amounts.
Top skills for insurance claims examiners
This career guide section outlines the skills and abilities that will help you find success as an insurance claims examiner.
Paying attention to detail is vital in evaluating insurance claims fairly and correctly. Missing minor details can result in inappropriate claim payouts, consequently impacting the company’s profitability and customer satisfaction.
To determine the validity of a claim, you’ll need to be able to examine and interpret complex information. This might include medical records, police reports, or damage assessments. Good analytical skills will enable you to make accurate and fair judgments.
Communication is key in this role. Examining insurance claims often involves discussion with claimants, insurance agents, and other parties. Communicating messages clearly and effectively — both verbally and in writing — contributes significantly to achieving a smooth process.
There may be times when there is a disagreement over the claim amount, where having the ability to negotiate effectively becomes important. You’ll need to find a solution that satisfies both the claimant and your employer.
Knowledge of insurance regulations and laws
Understanding insurance regulations and laws is vital in this role. Each type of insurance has its own set of regulations. By staying updated, you’ll be better positioned to ensure that all claim decisions comply with legal requirements.
Insurance claims examiner career path options
As an insurance claims examiner, your career options include multiple opportunities for growth and advancement. What’s important is that you leverage the skill set and experience you gain in this role to propel yourself forward.
Many claims examiners start their journey in an entry-level claims associate position, where foundational skills are built and experience is accumulated. Once you’ve honed your expertise and become proficient in handling various types of claims, you might advance to a senior claims examiner role or a team lead position. These roles often require you to manage more complex cases, mentor junior staff, or even oversee a team of examiners.
Another possible career progression is specialization. They can choose to specialize in a particular type of insurance, such as health, property, or casualty insurance. Specialized roles often command higher pay due to the specialized knowledge required. In addition to specialization, experienced examiners may choose to move into management roles. As a claims manager or director, you’d oversee the entire claims department, creating processes, setting goals, and ensuring the department adheres to various regulations and standards.
Lastly, the skills and knowledge gained as an examiner can be transferred to similar roles within insurance companies or across industries. Many decide to move into underwriting, risk management, or compliance roles. In underwriting, you’d evaluate the risk involved in insuring a person or asset and decide whether to provide the insurance or set the insurance premiums. Risk management involves identifying potential risks in an organization’s operations and proposing measures to reduce those risks. Compliance officers ensure that the company meets all its legal and regulatory requirements.
Similar job titles
Position trends and outlook for insurance claims examiners
The insurance sector continues to evolve, bringing about significant changes in the role of claims examiners. One of the notable trends impacting this profession is the adoption of integrated technology. There’s been a shift toward using advanced software tools and data analytics to streamline the claims process. Claims examiners are now expected to be familiar with these technologies to manage their tasks effectively. As a result, individuals intent on entering this field should focus not only on understanding the ins and outs of insurance claims but also on developing soft skills like analytical thinking, problem-solving, and familiarity with digital tools.
The automation process is also something they should keep an eye on. While automation has certain benefits, such as speeding up the claims process and reducing costs, it can also threaten job security. However, despite fears of job displacement, the expertise and personalized service examiners provide cannot be replaced entirely. Therefore, honing interpersonal skills, developing a deep understanding of claims policies and procedures, and maintaining a high level of integrity can help these professionals remain valuable in the sector.
The U.S. Bureau of Labor Statistics predicts employment for claims adjusters, appraisers, examiners, and investigators, which includes insurance claims examiners, to decline 6 percent through 2031 – due to automation and outsourcing of claims work. However, employment opportunities may arise from the need to replace workers who retire or leave the occupation for other reasons.
Insurance claims examiner career tips
Know the industry norms
To solidify your status as a competent claims examiner, you must be well-versed in industry norms and requirements. This knowledge aids your decision-making process when evaluating policyholder claims. Also, staying updated on the relevant legislation and state laws that govern insurance claims is paramount, as this can impact claim evaluations significantly.
Stay current with new evaluation techniques
Like many other professions, the technology and tools used in claim examination are constantly evolving. As professionals in this field, getting acquainted with these new developments is imperative. Familiarize yourself with up-to-date software and methodologies regularly used in claims evaluation, and if possible, incorporate them into your workflows.
Sharpen your communication skills
Among your responsibilities as an examiner will be to liaise with policyholders, legal representatives, and healthcare professionals to gather information and explain decisions. This role demands exceptional interpersonal and communication skills – both written and verbal. Exhibit empathy, clarity, and assertiveness in your interactions while maintaining professionalism.
Enhance your problem-solving abilities
Insurance claim examination often involves solving complex issues that require critical thinking and problem-solving abilities. Continue to develop these skills and learn to approach problems systematically. In doing so, you will be able to evaluate situations from multiple perspectives and make balanced decisions.
Build a professional network
Building a strong network can facilitate your growth in this career. Joining professional organizations allows you to interact with fellow examiners, learn from their experiences, and find mentors. Here are a few associations to consider:
- The Chartered Insurance Institute (CII)
- American Institute For Chartered Property Casualty Underwriters (AICPCU)
- The Institutes Risk & Insurance Knowledge Group
Foster continuous learning
The world of insurance is continually evolving, which demands continuous learning as part of your professional development. Staying up-to-date with the latest in the insurance sector will put you in a competitive spot and enhance your career progression. Some beneficial learning options might include:
- Taking advanced courses related to insurance law and practices
- Earn relevant certifications, such as the Certified Claims Professional (CCP) designation or the Chartered Property and Casualty Underwriter (CPCU)
- Regularly read industry-specific journals and magazines
Where the insurance claims examiner jobs are
- State Farm
- Liberty Mutual Insurance
- New York
Top job sites
What skills are necessary for insurance claims examiners?
Claims examiners must be comfortable dealing with numbers, have an analytical mindset, and have strong attention to detail. Their communication skills need to be top-notch, both written and verbal, to interact with claimants, insurance company representatives, and possibly attorneys. Additionally, they should be well-organized, as they’ll be handling multiple cases and may have to track large amounts of data.
What type of education or training is needed for insurance claims examiners?
Typically, a bachelor’s degree is required for this role, with a focus on fields like business, finance, or a related field. Some claims examiners may also have a background in law enforcement or health care. To supplement formal education, relevant experience in insurance, specifically in processing claims, would be highly beneficial. On-the-job training is also common, where they would learn the company’s specific procedures and protocols.
How much autonomy do insurance claims examiners typically have?
While the role requires collaboration with insurance representatives, attorneys, and other relevant parties, it also carries a high degree of autonomy. Claims examiners often have the authority to decide claim resolutions based on their analysis and the application of policy guidelines. They are also likely to manage multiple cases simultaneously, which requires a lot of independent work and time management.
What does a normal day look like for a claims examiner?
Every day can differ in this role, but generally, a claims examiner spends much of their time reviewing insurance claims filed by policyholders and medical providers. This includes verifying the claim details, evaluating the damage, and determining the insurance company’s liability. They might also negotiate settlements, communicate with relevant parties, and maintain thorough records for each case. At the same time, they must stay current on insurance and regulatory changes that may affect claims handling.
What industries employ insurance claims examiners?
While most of these professionals work for insurance carriers, they can also find work within brokerages, government agencies, and the healthcare sector. Some companies, such as large corporations with numerous assets, may employ their own claims examiners to manage their extensive insurance portfolios.
How does an insurance claims examiner differ from a claims adjuster?
While both roles exist to investigate and resolve insurance claims, the responsibilities and job scope vary. Claims adjusters often go into the field to evaluate damage firsthand and determine the cost of losses. On the other hand, an examiner primarily reviews the work conducted by the adjuster, scrutinizing it for completeness, accuracy, and adherence to policy guidelines before determining whether the insurer will pay the claim.
What is the most challenging part of being an insurance claims examiner?
The most challenging part can vary depending on the individual, but typically, navigating complex claims involving high amounts of money or various factors can be difficult. This requires an understanding of policy guidelines, strong critical thinking skills, and the ability to handle pressured situations. Communication can also be challenging, especially when interacting with dissatisfied policyholders or negotiating with other parties involved in a claim.
Are there any specific certifications for insurance claims examiners?
Although not always required, certifications can be beneficial and showcase an individual’s commitment and expertise in the field. There are multiple opportunities for certification, such as the Certification in Professional Claims Handling, Certified Claims Professional, and the Associate in Claims program. These are offered through various industry associations and cover topics like policy interpretation, various forms of insurance, claim legal aspects, and more.