Claims Examiner job description
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What does a Claims Examiner do?
The Claims Examiner plays a crucial role in ensuring the accuracy and fairness of insurance claims processing. This position is essential in maintaining customer trust and company profitability by meticulously reviewing and adjudicating claims in compliance with legal and policy standards.
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What are the Key Responsibilities of Claims Examiner
- Review and analyze insurance claims to determine coverage eligibility.
- Assess claims for accuracy and completeness, requesting additional information as necessary.
- Apply policy coverage and company guidelines to make informed decisions.
- Communicate with claimants and other parties to resolve discrepancies.
- Authorize claim payments within established limits and guidelines.
- Collaborate with legal and investigative teams for complex cases.
- Maintain accurate and detailed records of claims activities.
- Stay updated with industry regulations and company policies.
What are the Skills and Requirements for a Claims Examiner?
- Strong analytical and problem-solving skills.
- Excellent attention to detail and organizational abilities.
- Proficient in claims management software and MS Office.
- Effective communication and negotiation skills.
- Ability to make decisions based on guidelines and policies.
What are the KPIs to track for Claims Examiner?
The Claims Examiner's performance is evaluated based on claim processing efficiency, accuracy in adjudication, compliance with policy guidelines, and customer satisfaction with the claims service provided.
Processing Efficiency
Timely processing of claims adhering to established timelines.
Adjudication Accuracy
High accuracy rate in determining claim eligibility and payment.
Customer Satisfaction
Positive feedback and satisfaction scores from claimants.
Reports to
Claims Manager
Collaborates with
Claims Adjusters, Legal Team
Leads
N/A
Are any specific tools or software required for the Claims Examiner role?
- Claims Management Software
- MS Office Suite
- Policy Database Systems
What is the qualification of Claims Examiner?
Bachelor's degree in Insurance, Business Administration, or a related field, with 3-5 years of experience in claims examination or similar roles.
