Key Responsibilities and Required Skills for Claims Analyst

🎯 Role Definition

A Claims Analyst is responsible for investigating, evaluating, and processing insurance claims across personal, commercial, or specialty lines. This role requires strong analytical skills, familiarity with claim systems, regulatory knowledge, and the ability to communicate clearly with policyholders, providers, and internal stakeholders. The Claims Analyst helps control loss exposure, validates coverage and liability, documents claim activity, and supports timely, compliant claims settlements.

📈 Career Progression

Typical Career Path

Entry Point From:

Claims Representative / Claims Processor
Customer Service Representative in Insurance
Junior Insurance Analyst or Underwriting Assistant

Advancement To:

Senior Claims Analyst / Claims Specialist
Claims Supervisor / Team Lead
Claims Manager or Claims Operations Manager

Lateral Moves:

Subrogation Specialist
Loss Control Analyst
Fraud Investigator

Core Responsibilities

Primary Functions

Investigate new and existing claims by reviewing policy coverage, claim forms, medical records, police reports, and third-party documentation to determine liability, extent of loss, coverage limits, and potential fraud indicators.
Evaluate claims for compensability and financial exposure by estimating damages, calculating reserves, and recommending payments in accordance with policy terms and company guidelines.
Communicate directly with policyholders, claimants, medical providers, vendors, attorneys, and internal teams to gather missing documentation, clarify facts, and negotiate settlements while maintaining a professional and empathetic tone.
Process claim lifecycle activities from first notice of loss (FNOL) through closure, ensuring all actions are documented in the claims management system and within SLA timelines.
Prepare detailed claim notes, chronology, and case summaries that support claim decisions, litigation defense, and regulatory audits; maintain organized electronic and physical claim files.
Authorize and process payments for medical bills, repair estimates, indemnity payments, and vendor invoices, ensuring accuracy of payee information and adherence to payment controls.
Develop and maintain accurate indemnity and expense reserves and periodically re-evaluate reserves based on new information, loss development, and litigation outcomes.
Coordinate and manage subrogation and recovery actions, including referral to subrogation specialists and external counsel to maximize recoveries and reduce net claim costs.
Work with third-party administrators (TPAs), independent adjusters, appraisers, and vendors to coordinate field investigations, inspections, and repairs, ensuring timely delivery of expert reports.
Identify potential fraudulent or abusive claim activity through proactive review, flagging suspicious transactions, and escalating to the special investigations unit (SIU) when necessary.
Support litigation management by preparing claim files for defense counsel, responding to discovery requests, and tracking legal spend and outcomes in coordination with the legal team.
Analyze claim trends, loss drivers, and frequency/severity patterns and provide structured feedback to underwriting, risk control, and actuarial teams to inform pricing and risk selection.
Apply state and federal regulatory requirements, policy provisions, and industry best practices to adjudicate claims fairly and compliantly while documenting statutory notices and response timelines.
Facilitate medical bill reviews and utilization management activities by coordinating with nurse case managers and bill review vendors to control medical spend and ensure appropriate care pathways.
Implement and follow established claims handling workflows, continuous improvement initiatives, and quality assurance checks to ensure consistency and reduce cycle times.
Prepare periodic operational reports and KPIs such as closure rate, average time to resolution, loss ratio impact, and reserve adequacy for claims leadership and operational reviews.
Provide coaching, mentoring, and knowledge transfer to junior claims staff, participate in training sessions, and contribute to the development of standard operating procedures and playbooks.
Support catastrophe response and surge events by triaging incoming FNOL, prioritizing high-severity claims, and assisting with temporary staffing and workflow redistribution as needed.
Coordinate with billing departments and sub-contractors to resolve billing disputes, reconcile payments, and ensure accurate application of deductibles, sublimits, and policy endorsements.
Maintain current knowledge of medical terminology, repair estimating, liability law, and insurance policy language to make informed coverage and settlement determinations.
Assist with claim audits, regulatory examinations, and internal control testing by providing required documentation, explanations, and corrective action plans where applicable.
Participate in cross-functional projects to implement or optimize claims systems (e.g., Guidewire, Duck Creek), automation initiatives, or analytics tools to increase accuracy and operational efficiency.

Secondary Functions

Support ad-hoc reporting requests and exploratory analysis to help identify emerging claim trends, cost drivers, and opportunities for process improvement.
Collaborate with data analysts and actuarial teams to translate claim handling observations into measurable metrics and model inputs.
Participate in system configuration testing, user acceptance testing (UAT), and rollout activities for claims platform enhancements or vendor integrations.
Contribute to the design and maintenance of claim templates, standard letters, and workflow rules to ensure regulatory compliance and consistent claimant communication.
Assist in vendor selection and performance management for medical bill review, salvage, salvage disposal, and independent adjusting services.
Provide subject-matter expertise to underwriting and product teams on claim exposure and common coverage issues encountered in live claims.
Help refine fraud detection models by submitting annotated examples, participating in model validation activities, and translating field insights into features.
Support cross-training initiatives to ensure business continuity and coverage across lines of business during peak periods or absences.

Required Skills & Competencies

Hard Skills (Technical)

Proficiency with claims management systems such as Guidewire ClaimCenter, Duck Creek Claims, Xuber, or Insurity for end-to-end claim documentation, reserve management, and reporting.
Strong Microsoft Excel skills (VLOOKUP, INDEX/MATCH, pivot tables, data validation) for claims analysis, reserve rollforwards, and ad-hoc reporting.
Experience with SQL or basic data querying to extract claims data and perform root-cause analysis; familiarity with BI tools like Tableau, Power BI, or Qlik is a plus.
Working knowledge of insurance policy language, coverage forms, endorsements, exclusions, and basic principles of indemnity and liability.
Understanding of claims accounting concepts including incurred but not reported (IBNR), paid and outstanding losses, case reserves, and reinsurance reporting.
Familiarity with medical terminology, CPT/ICD coding, and procedures for handling medical-only, lost time, and catastrophic claims in health-related lines.
Competence in utilizing vendor portals and tools for bill review, subrogation, salvage, and outsourced adjusting; ability to manage vendor SLAs.
Experience preparing and tracking legal files, coordinating with defense counsel, and managing litigation costs and case outcomes.
Knowledge of state-specific regulatory requirements for claim handling, bad faith, timely notice, and statutory reporting obligations.
Ability to perform root-cause analysis and produce clear, actionable recommendations to reduce loss frequency and severity.
Basic knowledge of insurance fraud detection techniques, referral criteria, and collaboration with SIU and law enforcement as needed.
Familiarity with electronic medical records (EMR), repair estimating software, and claims imaging/document management best practices.

Soft Skills

Excellent written and verbal communication skills for clear, empathetic interaction with claimants, medical providers, and internal stakeholders.
Strong analytical and critical-thinking ability to synthesize complex information, identify trends, and make reasoned coverage and reserving decisions.
High attention to detail and organizational skills to maintain accurate claim documentation and meet regulatory timelines.
Customer-service orientation with the ability to de-escalate sensitive situations and manage expectations professionally.
Time management and prioritization skills to handle a high volume of claims while maintaining quality and meeting SLAs.
Good negotiation skills for settling claims efficiently while protecting company interests and minimizing litigation exposure.
Team collaboration and interpersonal skills to work cross-functionally with underwriting, actuarial, legal, and vendor partners.
Adaptability and resilience in a fast-paced environment, including handling catastrophe response and claim surges.
Problem-solving mindset with a continuous improvement approach to streamline processes and reduce cycle times.
Ethical judgment and integrity when handling confidential claimant information and sensitive claim matters.

Education & Experience

Educational Background

Minimum Education:

Associate degree or equivalent experience in Insurance, Business Administration, Finance, or related field.

Preferred Education:

Bachelor's degree in Risk Management, Insurance, Business, Finance, Healthcare Administration, or a related discipline.
Professional certifications such as AIC (Associate in Claims), CPCU, ARM, or RIPA are highly desirable.

Relevant Fields of Study:

Risk Management and Insurance
Business Administration
Finance
Healthcare Administration / Medical Billing

Experience Requirements

Typical Experience Range: 2 - 5 years of claims handling experience for mid-level analyst roles; entry-level roles may accept 0-2 years with relevant internship or customer-service experience.

Preferred:

3+ years handling property & casualty, casualty liability, workers’ compensation, or specialty line claims depending on role focus.
Demonstrated experience with claims systems (Guidewire, Duck Creek), reserve setting, subrogation, and litigation management.
Prior exposure to analytics, Excel modeling, or SQL-based reporting is preferred for roles that include data-driven responsibilities.