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Key Responsibilities and Required Skills for Insurance Claims Examiner

💰 $ - $

🎯 Role Definition

An Insurance Claims Examiner is responsible for investigating, evaluating, and resolving insurance claims across personal and commercial lines (e.g., auto, property, liability, workers' compensation, medical). This role requires careful policy interpretation, thorough investigation, accurate reserve-setting, and timely claims adjudication while maintaining regulatory compliance, mitigating risk, and delivering a high level of customer service. The ideal candidate blends strong analytical aptitude, claims systems proficiency, knowledge of insurance law and coverage, and effective negotiation and communication skills.

📈 Career Progression

Typical Career Path

Entry Point From:

  • Claims Representative / Claims Processor
  • Customer Service Representative in Insurance
  • Field Claims Adjuster or Claims Intern

Advancement To:

  • Senior Claims Examiner / Senior Claims Adjuster
  • Claims Supervisor or Team Lead
  • Claims Manager / Claims Operations Manager
  • Specialty Adjuster (e.g., Major Loss, Liability, Workers' Comp)
  • Subrogation or Fraud Investigation Specialist

Lateral Moves:

  • Underwriting or Risk Management
  • Loss Control / Safety Consultant
  • Reinsurance Analyst
  • Customer Success / Account Management for TPAs

Core Responsibilities

Primary Functions

  • Perform end-to-end claims adjudication for assigned caseloads: intake, triage, coverage analysis, investigation, liability determination, reserve recommendation, negotiation, settlement authorization, and claim closure in accordance with company policies and regulatory requirements.
  • Review and interpret insurance policies, endorsements, and limits to determine coverage applicability and exclusions; clearly document coverage rationale and communicate coverage determinations to claimants, agents, and internal stakeholders.
  • Conduct detailed investigations by obtaining and reviewing police reports, medical records, witness statements, photographs, repair estimates, and other relevant documentation to establish facts and identify responsible parties.
  • Evaluate liability and causation by analyzing loss circumstances, applying legal and policy principles, and consulting with legal counsel or senior examiners when complex coverage or subrogation issues arise.
  • Establish, monitor, and revise claim reserves based on investigative findings, indemnity exposure, legal exposure, and projected settlement strategies; present reserve changes for supervisory review when required.
  • Negotiate settlements with claimants, attorneys, medical providers, and other parties to achieve fair, cost-effective resolutions while protecting company interests and minimizing future exposure.
  • Coordinate with external partners including independent adjusters, medical providers, repair shops, appraisers, vendors, and third-party administrators (TPAs) to secure timely estimates, bills, and services needed to resolve claims.
  • Make timely and accurate claim payments, process checks or electronic funds transfers, and reconcile payment documentation in the claims management system in line with authority limits and audit requirements.
  • Identify potential subrogation and recovery opportunities; open subrogation files, pursue recovery actions, and coordinate with subrogation specialists and legal teams to maximize reimbursements.
  • Detect potential fraud indicators through data analysis and investigative techniques; refer claims for special investigations, collaborate with SIU teams, and document suspicious activities to comply with anti-fraud protocols.
  • Manage bodily injury and medical-only claims by obtaining medical authorizations, compiling medical summaries, assessing treatment reasonableness, and coordinating independent medical examinations (IMEs) when necessary.
  • Administer indemnity and wage-loss claims for workers’ compensation by verifying compensability, confirming employer details, calculating benefits, and ensuring timely benefit payments and documentation.
  • Prepare comprehensive claim reports, chronologies, and recommended action plans for complex or litigated claims to support litigation strategy and settlement discussions.
  • Issue and review reservation of rights letters, denial letters, and other regulatory-required correspondence; ensure written communications are timely, legally sound, and clearly explain company positions.
  • Collaborate with defense counsel and litigation management teams on reserving strategy, discovery responses, witness interviews, pre-trial preparation, and settlement authority requests for litigated matters.
  • Maintain accurate, timely electronic file documentation and adhere to file-handling standards and audit controls to ensure regulatory compliance and readiness for audits or litigation.
  • Monitor claim inventory and key performance indicators (e.g., cycle time, closure rate, severity trends); implement workflow changes or escalation plans to manage backlog and meet departmental service-level agreements (SLAs).
  • Provide guidance, mentorship, and training to less experienced examiners and support staff, review their files for quality assurance, and participate in coaching and development activities.
  • Participate in claim audits, quality reviews, and post-settlement analyses to identify process improvements, root causes, and opportunities to reduce leakage and improve outcomes.
  • Collaborate cross-functionally with underwriting, risk control, actuarial, and customer service teams to share claim trends, loss drivers, and policy wording issues that impact pricing and product offerings.
  • Manage high-profile and catastrophic claims by coordinating multi-disciplinary resources, tracking large-dollar exposures, liaising with senior leadership, and implementing rapid-response plans to protect insureds and company interests.
  • Administer coverage disputes and appeals by researching case law, regulatory guidance, and precedent claims; recommend positions and settlement parameters based on risk tolerance and business objectives.
  • Ensure compliance with federal, state, and local regulations (including privacy and medical confidentiality laws) and company policies when handling personal data, billing, and claims communications.
  • Proactively communicate claim status, next steps, and settlement options to claimants, policyholders, agents, and internal stakeholders to maintain transparency and drive timely resolutions.

Secondary Functions

  • Support process improvement initiatives by analyzing claim workflow, proposing automation opportunities, and participating in pilot programs for claims technology or analytics.
  • Assist in data collection and ad-hoc reporting requests to help the claims leadership team monitor trends, loss ratio drivers, and vendor performance.
  • Participate in cross-functional meetings to translate operational challenges into system requirements and to test enhancements in the claims management system (e.g., Guidewire, Duck Creek, ClaimCenter).
  • Help maintain up-to-date playbooks, templates, and standard operating procedures (SOPs) for common claim types and ensure consistent application across the team.
  • Serve as a subject matter resource for new product launches or policy changes by reviewing claim impacts and supporting training efforts for front-line staff.
  • Contribute to disaster response and catastrophe claims handling plans, including surge staffing, triage protocols, and coordination with emergency services.
  • Conduct peer file reviews and assist with internal audit remediation plans to close findings and improve compliance posture.
  • Support vendor selection and performance reviews for medical bill review, utilization review, appraisal, or salvage services.

Required Skills & Competencies

Hard Skills (Technical)

  • Claims adjudication and file management (end-to-end claims lifecycle experience).
  • Policy interpretation across lines: auto (P&C), homeowners, commercial property, general liability, and workers' compensation.
  • Reserve analysis and claim exposure assessment, including experience setting and adjusting loss reserves.
  • Strong investigative skills: obtaining and analyzing police reports, medical records, expert reports, and loss documentation.
  • Negotiation and settlement authority management, including interacting with counsel and structured settlement experience.
  • Subrogation and recovery processes, including lien resolution and coordination with recovery teams.
  • Familiarity with claims management systems (e.g., Guidewire ClaimCenter, Duck Creek, ClaimLogix, Insurity) and basic database/reporting tools.
  • Understanding of medical terminology, billing codes (CPT, ICD), and experience working with medical providers or bill review vendors (especially for BI and WC claims).
  • Knowledge of relevant federal and state laws and regulations affecting claims handling, including privacy/HIPAA issues for medical records.
  • Fraud detection indicators and working knowledge of Special Investigations Unit (SIU) referral processes.
  • MS Office proficiency: Excel for analytics, Word for correspondence, Outlook for stakeholder communications.
  • Experience coordinating with defense counsel, litigation management, and document production for legal proceedings.
  • Basic familiarity with reinsurance concepts, salvage, and recoverable expense handling.

Soft Skills

  • Exceptional written and verbal communication skills; able to write clear, defensible denial and settlement letters.
  • Strong analytical and critical thinking skills with attention to detail and ability to synthesize complex information.
  • Customer-centric mindset with professional empathy when interacting with claimants, insureds, and medical providers.
  • Effective negotiation and conflict-resolution skills, maintaining composure in high-pressure or adversarial situations.
  • Time management and prioritization skills to manage large caseloads while meeting SLAs and regulatory deadlines.
  • Sound judgment and decision-making autonomy, with ability to escalate complex matters appropriately.
  • Team player who collaborates across functions and mentors junior staff.
  • Adaptability to process and system changes; continuous improvement orientation.
  • Ethical integrity and commitment to compliance, confidentiality, and unbiased claim handling.
  • Problem-solving mindset with capability to recommend process improvements and drive operational efficiencies.

Education & Experience

Educational Background

Minimum Education:

  • High school diploma or GED required; associate degree or equivalent experience in insurance acceptable.

Preferred Education:

  • Bachelor's degree in Business, Risk Management, Insurance, Finance, Legal Studies, or related field.
  • Professional certifications preferred: AIC (Associate in Claims), CPCU, ARM, CIC, or related insurance credentials.

Relevant Fields of Study:

  • Insurance & Risk Management
  • Business Administration or Finance
  • Paralegal Studies or Legal/Compliance
  • Healthcare Administration (for medical claims)

Experience Requirements

Typical Experience Range:

  • 2–6 years of direct claims examination or adjuster experience; for senior roles 5–10+ years depending on claim complexity and line of business.

Preferred:

  • Prior experience in the specific line of business (e.g., P&C, Auto BI, Commercial Lines, Workers' Compensation).
  • Demonstrated experience with claims systems (Guidewire, Duck Creek) and compliance with state regulatory frameworks.
  • Experience handling complex, litigated, or catastrophic claims and working with outside counsel and medical experts.
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