Key Responsibilities and Required Skills for Insurance Claims Clerk

🎯 Role Definition

An Insurance Claims Clerk is responsible for the accurate intake, processing, documentation, and administration of insurance claims across personal, commercial, and/or health lines. This role emphasizes efficient claims workflow management, careful verification of coverage and policy information, preparation and routing of claim files to adjusters or payment teams, and consistent communication with claimants, providers, and internal stakeholders. The Insurance Claims Clerk ensures compliance with regulatory and company procedures (HIPAA, state insurance codes), maintains high-quality file documentation, and supports continuous process improvement initiatives to reduce cycle time and improve customer satisfaction.

📈 Career Progression

Typical Career Path

Entry Point From:

Customer Service Representative (insurance contact center)
Data Entry Clerk or Administrative Assistant with insurance exposure
Medical Billing Specialist or Receptionist converted into claims

Advancement To:

Senior Claims Clerk / Claims Specialist
Claims Adjuster or Examiner (Property & Casualty or Health)
Claims Supervisor or Team Lead
Claims Analyst or Quality Assurance Specialist
Underwriting Assistant or Policy Administration Lead

Lateral Moves:

Billing and Payment Posting Specialist
Provider Relations or Medical Records Coordinator
Customer Service Representative (specialized in claims support)
Policy Administration / Renewals Coordinator

Core Responsibilities

Primary Functions

Receive, triage, and log incoming claims via phone, email, fax, and EDI channels into the claims management system (e.g., Guidewire, Duck Creek, CCC ONE) ensuring complete and accurate intake data for timely processing.
Verify policyholder information, policy numbers, effective dates, limits, deductibles, and coverage applicability to determine claim eligibility before routing to the appropriate claims handler.
Review and validate attached documentation (police reports, medical records, repair estimates, invoices) for completeness and flag missing items for follow-up to reduce processing delays.
Assign claim numbers, create and maintain claim files, and ensure all correspondence, notes, and scanned documents are correctly indexed and retained per company retention policies and regulatory requirements.
Adjudicate simple, first-notice claims and routine payments (e.g., small property losses or subrogation holds) within established authority limits and escalate complex claims to adjusters or examiners.
Process claims payments, write checks, or initiate electronic remittance advice (ERA) and post payments to the ledger, reconciling payment details with claimant and provider invoices.
Enter and update claim activity and reservation amounts (reserves) in the claims administration system following standard operating procedures and audit trails.
Investigate claimant and provider inquiries regarding claim status, payments, denials, and documentation requirements and provide clear, professional explanations to internal and external customers.
Coordinate requests for medical records, bills, estimates, and other supporting documentation; follow up with providers and vendors to obtain outstanding items necessary for claim resolution.
Communicate with third-party administrators, adjusters, repair facilities, lawyers, and medical providers to collect information and schedule inspections or appointments as required for claim progression.
Audit claim files for quality assurance purposes, identifying incomplete documentation, incorrectly coded services, or compliance gaps, and take corrective action or escalate for remediation.
Process denials, reopenings, subrogation referrals, and recoveries with accurate documentation and timely routing to the subrogation or recovery teams.
Maintain confidentiality and ensure HIPAA and privacy compliance when handling protected health information and claimant personal data.
Monitor claim timeliness metrics (Aging, Days to First Contact, Cycle Time) and work assigned inventory to meet service-level agreements (SLAs) and performance targets.
Prepare and deliver periodic status reports and dashboards for supervisors and claims managers highlighting backlog, bottlenecks, and high-priority files.
Support litigation and reserving teams by compiling claim histories, chronology, and exhibits for legal review and discovery as requested.
Reconcile EOBs (explanation of benefits), ERA files, and carrier remittance data to internal claim records to ensure payment accuracy and identify overpayments or underpayments.
Initiate and process provider and vendor payments, set up vendor files, and ensure W9s and contract documentation are on file as required.
Conduct preliminary investigations for suspected fraud indicators and refer suspicious activity to the special investigations unit with documented evidence.
Train and mentor new clerical hires on claims intake procedures, documentation standards, and claims systems/navigation to maintain consistent team performance.
Implement and recommend process improvements and participate in cross-functional initiatives to streamline claims workflows, reduce errors, and lower cycle times.

Secondary Functions

Support ad-hoc reporting requests and assist in compiling claims metrics for operational reviews and audits.
Participate in periodic internal and regulatory audits and provide requested claim documentation and process explanations.
Assist in maintaining and updating claims forms, checklists, templates, and standard operating procedures.
Participate in cross-training with subrogation, payment posting, and customer service teams to provide coverage during peak volume periods or staff shortages.
Help coordinate vendor relationships and onboarding for third-party administrators, repair shops, and medical providers.
Escalate system issues, data integrity concerns, or vendor disputes to appropriate leads and follow through to resolution.
Contribute to training material updates and knowledge base articles for common claims scenarios and frequently asked questions.
Participate in quality reviews and root-cause analysis sessions to reduce recurring errors and support continuous improvement.

Required Skills & Competencies

Hard Skills (Technical)

Claims intake and claims processing experience with property & casualty, auto, home, or health claims.
Hands-on experience with claims management systems (Guidewire, Duck Creek, CCC ONE, ClaimCenter) and basic system administration tasks.
Proficient in Microsoft Office (Excel for reconciliation and reporting, Outlook, Word) and experience with document imaging/scanning software.
Familiarity with EDI X12 claims transactions, ERA (Electronic Remittance Advice), and clearinghouse processes.
Knowledge of insurance policy structure, coverage terms, deductibles, limits, subrogation, and salvage processes.
Experience with payment posting, check preparation, EFT processing, and general ledger reconciliation.
Working knowledge of HIPAA, state insurance regulations, and record retention/compliance requirements.
Ability to read and interpret medical records, repair estimates, police reports, and invoice documentation.
Basic coding knowledge (ICD-10, CPT) for health claims or familiarity with vehicle repair codes/estimating for P&C lines.
Strong data entry speed and accuracy, with experience in maintaining audit trails and claim histories.
Experience preparing files and documents for legal counsel and participating in discovery or litigation support.
Familiarity with customer relationship management (CRM) or contact center platforms used for claimant communication.
Use of workflow tools and ticketing systems to manage claim-related tasks and escalations.

Soft Skills

Exceptional attention to detail and accuracy in documenting claim activity and financial transactions.
Strong verbal and written communication skills for interacting with claimants, providers, vendors, and internal stakeholders.
Customer-centric mindset with empathy for claimants and the ability to manage difficult conversations professionally.
Time management and organizational skills to prioritize large volumes of claims and meet SLA targets.
Problem-solving and analytical skills to identify discrepancies, root causes, and appropriate remediation steps.
Team player attitude with the ability to collaborate across claims, subrogation, and legal teams.
Adaptability and resilience in high-volume, deadline-driven environments.
Discretion and integrity when handling sensitive personal and medical information.
Initiative to identify process improvements and drive small-scale operational change.
Ability to learn and adopt new claims technology and process changes quickly.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED required.

Preferred Education:

Associate degree or vocational certificate in Insurance, Business Administration, or related field.
Industry certifications such as AINS (Associate in General Insurance), CISR, or claims-specific credentials are a plus.

Relevant Fields of Study:

Insurance / Risk Management
Business Administration
Health Information Management / Medical Billing
Paralegal Studies (for litigation-support tracks)

Experience Requirements

Typical Experience Range:

1 to 3 years of direct claims clerical or insurance customer service experience.

Preferred:

2 to 5 years of claims processing experience with exposure to claims systems and payment posting.
Experience in the specific line of business (Auto, Property, Workers’ Compensation, Health) preferred depending on the role.