HR management

Claims examiner job description
(Insurance Adjuster, Examiner, or Investigator)

Job purpose of claims examiner is to review settled insurance claims to determine that payments and settlements have been made in accordance with company practices and procedures.

Key duties of claims examiner:

1. Investigate, evaluate and settle claims, applying technical knowledge and human relations skills to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio.

2. Pay and process claims within designated authority level.

3. Adjust reserves and provide reserve recommendations to ensure reserving activities consistent with corporate policies.

4. Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation.

5. Resolve complex, severe exposure claims, using high service oriented file handling.

6. Contact and/or interview claimants, doctors, medical specialists, or employers to get additional information.

7. Confer with legal counsel on claims requiring litigation.

8. Report overpayments, underpayments, and other irregularities.

9. Communicate with reinsurance brokers to obtain information necessary for processing claims.

10. Supervise claims adjusters to ensure that adjusters have followed proper methods.

11. Conduct detailed bill reviews to implement sound litigation management and expense control.

12. Prepare reports to be submitted to company’s data processing department.

13. Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.

14. Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.

15. Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments.

16. Present cases and participate in their discussion at claim committee meetings.

Related documents:

• Insurance job descriptions
• Insurance interview questions

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