Claims examiners are the army of well-trained professionals that insurance companies rely on to rein in fraud and waste in operating activities. Examiners combine investigative skills and analytical dexterity to review payment requests that policyholders make. Claims reviewers also report overpayments, underpayments and other irregularities, saving insurers substantial sums in the short and long terms.
Investigate Payment Requests
Poring over insurance claims remains the purview of claims examiners. Reviewers apply technical knowledge and interpersonal skills to promptly investigate claims and reduce corporate loss ratios. These metrics are cardinal for insurance industry executives, because they provide insight into how much companies pay out on claims on each premium dollar collected. Claims examiners also help resolve complex, severe-exposure claims, working in tandem with other professionals, such as actuaries and law enforcement.
Appraise Costs
Cost appraisals indicate to insurance industry regulators whether claims examiners are successful at identifying and correctly evaluating claims-related expenses. A product of mathematical accuracy and accounting analysis, cost appraisal is an important exercise that limits insurers' payment outflows. To effectively evaluate costs, claims examiners contact or interview claimants, doctors and law enforcement; verify and analyze claims data to ensure accuracy; and ensure that settlements are in line with corporate policies.
Ensure Regulatory Compliance
Claims reviewers ensure that policyholders conform to corporate guidelines when filing payment requests. Examiners also make sure settlements abide by federal laws and regulations as well as industry-specific guidelines. These include National Association of Insurance Commissioners rules, Occupational Safety and Health Administration norms and U.S. Department of Health and Human Services directives. To perform tasks in accordance with laws, claims examiners use the tools of the trade. These include expert system software; document management and analysis programs; claims processing, administration and management software; and insurance-claims fraud detection software.
Education and Pay
A college degree is generally necessary for a claims examiner position, according to the U.S. Bureau of Labor Statistics. However, employers often consider candidates who have at least a high school diploma or GED certificate. On-the-job training and regular classroom instruction enable novice examiners to learn the ropes of the profession and improve their earning power. As of 2010, a claims examiner earned an average salary ranging from $35,256 to $63,103, according to employment data portal PayScale.
Occupational Affiliation
In modern economies, claims examiners perform similar duties as other insurance-industry professionals. These workers include claims adjusters and representatives, claims analysts and managers, customer care specialists and home-office claims specialists, according to O*Net Online, the U.S. Department of Labor's occupational research branch. The online job resource Earn My Degree indicates that insurance policy processing clerks, underwriters and cost estimators also execute duties similar to claims examiners.
