How to become A Claims Examiner

Comprehensive knowledge of insurance policies and regulatory guidelines, meticulous attention to detail, and a strong work ethic drive Claims Examiners to review claim forms and make sure all stakeholders adhere to the correct procedures.

• Claims Reviewer

What do Claims Examiners do?

A Claims Examiner would typically need to:

• Review, examine, calculate, and authorise insurance claims investigated and filed by claims adjusters
• Determine if an insurance policy covers the loss claimed; gather information from claimants and witnesses to assess claims for eligibility and accuracy
• Collect and analyse relevant documents, including medical records, police reports, and witness statements; visit accident scenes to evaluate damages
• Analyse relevant documentation to ensure that claims are not fraudulent and all involved parties follow proper guidelines
• Make certain all claims adhere to corporate policies and procedures as well as regulatory norms
• Decide the appropriate sum to be paid by the insurance company; watch out for claims that involve excess or reduced payments
• Investigate irregularities and file a report after consultation with relevant professionals
• Contact experts, such as attorneys, engineers, architects, and doctors to analyse the merit of claims and get additional information on questionable claims
• Review a claim to decide whether to approve, deny, or refer it to a claims investigator; meet claimants to resolve differences and negotiate settlements
• Authorise payments after getting due approval from a relevant senior; manage appropriate confidentiality during the entire process
• Recommend a case against the policy holder, if the situation warrants one; work closely with the legal counsel and other experts during the litigation process
• Evaluate life insurance policies to determine whether the applicants fall under the category of high-risk life insurance
• Calculate benefits and payments due on specific policies; provide exemplary customer service and advice
• Assist claims adjusters in handling heavy case loads; produce and share detailed reports on claim findings with colleagues and management

Claims Examiners typically work in an office environment. However, they may need to travel to evaluate property damage and discuss claim details with clients, insurance agents, and experts. Remote work options are becoming more popular.

Full-time Claims Examiners usually have regular work schedules; they may need to work evenings and weekends in response to employer and client demands. 

Research suggests that flexible hours and generous telework policies appeal more than salary to the younger generation. There has been an incremental increase in employers willing to give promising employees a chance to adjust their schedules per the job demands.

Finding a new job might seem challenging. Claims Examiners can boost their job search by asking their network for referrals, contacting companies directly, using job search platforms, going to job fairs, leveraging social media, and inquiring at staffing agencies. 

Claims Examiners are generally employed by:

• Insurance Companies
• Property & Casualty (P&C) Businesses
• Third-party Administrators
• Independent Adjusting Firms
• Hospitals

Professional associations and organisations, such as the International Association of Claims Professionals (IAClPro), are crucial for Claims Examiners interested in pursuing professional development or connecting with like-minded professionals in their industry or occupation. 

Professional associations provide members with continuing education, networking opportunities, and mentorship services. Membership in one or more adds value to your resume while bolstering your credentials and qualifications.

• Handling a large volume of claims in an accurate and timely manner
• Making fair and informed decisions in the face of intricate policy provisions, multiple parties, and disputed liability
• Emotional and occasionally difficult conversations with individuals experiencing stressful situations, including accidents, property damage, or health issues
• Strict adherence to constantly evolving industry regulations, company policies, and legal requirements
• Resolving conflicts between claimants, policyholders, and service providers while managing customer expectations satisfactorily
• Digital transformation that spells a learning curve and potential resistance to change
• Meeting or exceeding performance metrics and targets, such as processing times, accuracy rates, and customer satisfaction scores while maintaining quality
• Stunted job growth in regions with decline in direct insurance carriers
• Potential dangers involved in the inspection of damaged or weakened structures, if employed in the P&C insurance sector
• Potential lack of work-life balance when required to put in extra hours

Summer internships, part-time work at an entry-level position or short-term paid/voluntary work in the insurance industry offer opportunities to work on small claims under the supervision of more experienced colleagues, give valuable insight into how a company operates, help build valuable contacts and improve one’s prospects of getting a permanent job. 

Where the curriculum includes internships, prospective Claims Examiners will benefit from tasks outside of the classroom that aligns with lessons inside it. One may hear countless stories from more experienced professionals and obtain valuable hands-on experience when they turn seemingly routine incidents into unique learning moments.

The experience may also help determine whether the public, private or voluntary sector is best suited to realise one’s ambitions. Your educational provider’s career service department can provide information about viable work placement, internship, and voluntary work opportunities in diverse sectors.

Even while in high school, you can check with a teacher or counsellor about relevant work-based learning opportunities available in your school or community that can help you connect your school experiences with real-life work.

Join debate teams, maths clubs, or puzzle-solving groups to develop critical thinking, analytical reasoning, and problem-solving skills. The school computer club can help you get acquainted with spreadsheets, databases, and word-processing tools while gaining proficiency in using online research resources and technology. 

Read about the profession and interview or job shadow experts in the insurance industry to prove your commitment to course providers and prospective employers.

Although a high school diploma or equivalent may suffice to work as an entry-level Claims Examiner, employers and clients prefer applicants with a bachelor’s degree in insurance and risk management that familiarise students with all kinds of insurance, insurance legislation, and risk management theory.

Although most favour business administration, finance, or accounting, some aspirants choose a major based on the type of insurance they wish to specialise in. For example, an auto claims examiner might hold a degree in automotive repair, while one in property damage claims examination might opt for an architectural or engineering degree.

An associate or certificate programme in claims and medical claims examinations, including industry-specific language, different kinds of claims, and customer service, may increase one’s chances of employment.

Recommended high school courses include algebra, statistics, business studies, psychology, economics, and office skills. English and speech classes will help you develop your research, writing, and oral communication skills.

Remember that completing a particular academic course does not guarantee entry into the profession. Be that as it may, professional qualifications and transferable skills may open up more than one door.

Do your homework and look into all available options for education and employment before enrolling in a specific programme. Reliable sources that help you make an educated decision include associations and employers in your field.

Certification demonstrates a Claims Examiner’s competence in a skill set, typically through work experience, training, and passing an examination. Successful certification programs protect public welfare by incorporating a Code of Ethics.

Certification in claims, general insurance, billing and coding, property casualty underwriting, and work adjustment from an objective and reputed organisation can help you stand out in a competitive job market and carry a significant salary premium of up to 18 per cent.

Examiners may require a license to practice. Individual government entities conduct the licensing process. It requires passing an examination after completing prelicensing education. Some regions may accept either of the two conditions or require a simple registration.

Examiners working on life and health claims must stay updated on the latest medical procedures and prescription drugs. In contrast, those working on auto claims must know about recent car models and repair techniques. 

Claims Examiners may also need to undergo an employment background check, including but not limited to a person’s work history, education, credit history, motor vehicle reports (MVRs), criminal record, medical history, use of social media, and drug screening.

Performance, experience, the acquisition of professional qualifications, and the specific organisation and industry drive the career progression of Claims Examiners who may be promoted as Senior Claims Examiners before they become Claims Supervisors/Managers.

One may also transition to a Claims Operations Analyst or Claims Adjuster role. Eventually, it is also possible to move into higher-level management positions, such as Claims Department Manager/Director.

The desire to accelerate career growth and personal development has an increasing number of millennials choosing to job hop and build a scattershot resume that showcases ambition, motivation, and the desire to learn a broad range of skills.

Studies prove that job hopping, earlier dismissed as “flaky” behaviour, can lead to greater job fulfilment. Employees searching for a positive culture and interesting work are willing to try out various roles and workplaces and learn valuable, transferable skills along the way.

Detail-oriented Claims Examiners with requisite analytical, communication, interpersonal, and negotiation skills, a strong work ethic, a bachelor’s degree in insurance or risk management, accredited claims and general insurance certifications, and significant work experience have the best job prospects.

Continuing professional development (CPD) will help an active Claims Examiner build personal skills and proficiency through work-based learning, a professional activity, 

formal education, or self-directed learning. 

Large insurance companies may have sufficient resources to provide continuous internal training and professional development opportunities to their Claims Examiners so they keep abreast of the latest changes in insurance policies, regulations, and industry practices. Smaller companies lacking similar resources may provide educational assistance to their employees.

Increased expertise in claims investigation and settlement typically leads to the assignment of larger, more complex claims. Enrol in classes, attend workshops, write articles for claims publications, or give lectures and presentations to obtain continuing education credits.

Automation is on the rise; make the most of relevant computer software to evaluate pictures of damaged property and calculate an estimated claim amount. The consequent data collection and processing speed increase will improve your efficiency and productivity.

In addition to offering the opportunity to continually upskill, regardless of one’s age, job, or level of knowledge, CPD also enables the periodic renewal of desirable certifications, which increase your chances of advancement and becoming an independent consultant.

To Get Your Facts Straight

Claims Examiners need excellent communication, interpersonal and negotiation skills to gather information, explain coverage details, transact settlements, and address any concerns or disputes. They are trained to identify suspicious patterns, inconsistencies, or exaggerations in claims. 

Forward-thinking professionals use software applications, data analytics, and artificial intelligence tools to streamline claim processing, enhance accuracy, and expedite informed decision-making. 

Above all, accomplished Claims Examiners build positive relationships and ensure customer satisfaction by offering support, answering queries, explaining claim status updates, and providing guidance on requisite documentation.

Which Would Be Your Chosen Path?

Claims Examiners can specialise in and handle claims related to one or more of the diverse insurance fields, including auto, property, health, and workers' compensation and liability insurance.

Current Scenario

The employment outlook of Claims Examiners may be impacted by diverse factors, such as location, specific industry, regional economic conditions, and technological advances.

While increased automation is seen as a cause for declining job growth, technology can help make Claims Examiners more efficient and productive. Ongoing insurance claims, new claims arising from various events, and the need to replace workers retiring from active service or transferring to other occupations also lead to significant job openings. 

The projected increase in the frequency and number of natural disasters, such as floods and fires, may translate into some employment growth in P&C insurance. An ageing baby boomer population with rising health issues anticipates a demand for Claims Examiners to review a growing number of insurance claims from elderly patients.

A burglar who failed to escape locked himself in the garage for a week because of a faulty garage opener and filed an insurance claim for USD 1 million against the owner for mental anguish.

The infinite satisfaction Claims Examiners derive from a job well done makes the regular tedium and emotional stresses of their work worth the while.

Have meaningful and transparent conversations with claimants and other stakeholders to gather the information most relevant to each claim.