Key Responsibilities and Required Skills for Insurance Claims Processor

🎯 Role Definition

The Insurance Claims Processor is responsible for end-to-end claims handling: intake, investigation, adjudication, negotiation, payment processing, and closure. This role requires interpreting policy language, validating coverage, identifying fraud and subrogation opportunities, communicating with claimants and providers, and documenting decisions in the claims management system. The Claims Processor balances speed and accuracy to meet SLAs, minimize loss, and deliver an excellent customer experience while complying with regulatory and company guidelines.

📈 Career Progression

Typical Career Path

Entry Point From:

Claims Clerk / Claims Intake Specialist
Customer Service Representative or Call Center Agent with insurance exposure
Auto or Property Adjuster Assistant

Advancement To:

Senior Claims Processor / Adjudicator
Claims Supervisor / Team Lead
Claims Manager or Claims Operations Manager
Specialty Adjuster (e.g., Catastrophe, Large Loss) or Underwriting Specialist

Lateral Moves:

Subrogation Specialist
Fraud Investigation Analyst
Provider Relations / Medical Review Specialist

Core Responsibilities

Primary Functions

Receive and triage incoming claims from multiple channels (phone, portal, email, EDI) and perform timely first-contact intake, verifying policyholder data and establishing claim files in the claims management system.
Review policies and endorsements to determine coverage, limits, exclusions and respond with clear coverage determinations to claimants and internal stakeholders.
Conduct thorough investigations of property, casualty, auto, or medical claims by collecting statements, photos, police reports, medical records, bills, and other supporting documentation to establish liability and damages.
Adjudicate claims by applying policy language and company guidelines to calculate reserves, determine payment amounts, approve or deny benefits, and prepare detailed claim notes and rationale.
Process claim payments, drafts, and electronic payments accurately and within established SLA windows; ensure proper documentation and approvals for all disbursements.
Analyze explanations of benefits (EOBs), itemized medical bills, CPT/ICD codes and typical charge patterns to validate billed services and support appropriate pricing or negotiated provider rates.
Manage provider and vendor relationships (repair shops, medical providers, third-party administrators) to obtain estimates, treatment plans, liens, and negotiated invoices; escalate disputes when necessary.
Identify potential subrogation, salvage, or recovery opportunities and refer or assign claims to subrogation specialists with detailed supporting documentation and preservation of evidence.
Evaluate claims for potential fraud indicators; document suspicious patterns and coordinate with internal Special Investigation Unit (SIU) or third-party investigators to escalate and preserve claims.
Set, adjust, and monitor claim reserves based on investigation findings, loss projections, and communication with actuarial or reserving teams; justify material reserve increases or releases.
Communicate proactively with claimants, insureds, brokers, attorneys and internal teams to provide status updates, explain decisions, and resolve escalations while documenting all interactions.
Negotiate settlements with claimants, policyholders, and counsel to achieve fair, timely resolution within authority limits while protecting company interests and minimizing litigation exposure.
Prepare, review and respond to subpoenas, litigation hold notices and coordinate with legal counsel for claims that progress to litigation; ensure files meet discovery and trial readiness standards.
Ensure regulatory compliance with state insurance code, privacy laws (HIPAA for medical claims), statutes of limitations, and notice requirements for workers’ compensation or no-fault jurisdictions.
Audit claim files for quality assurance and adherence to internal controls, identify trends in leakage or process gaps, and implement corrective actions to improve accuracy and cycle time.
Reconcile EDI claim transmissions (837/835) and remittance advice to ensure payments and adjustments are properly applied; work with IT or vendors to resolve transmission errors.
Use claims analytics and reporting tools to monitor KPIs (cycle time, average payment, denial rate, reopened claims) and provide actionable insights to reduce expense ratios and improve customer satisfaction.
Participate in claim reviews, cross-functional problem-solving sessions and process improvement initiatives (Lean, Six Sigma, or Kaizen) to streamline workflow and automate repetitive tasks.
Mentor and coach junior claims staff by sharing best practices, conducting file reviews, and providing on-the-job training to maintain a high-performing claims team.
Maintain accurate, timely, and auditable claim documentation in accordance with company record retention policies and industry best practices.
Execute special projects such as system conversions, rates or rule updates, and vendor transitions; test claim workflows and validate data integrity during system changes.
Coordinate catastrophic or large-loss response efforts including surge handling, triage, vendor mobilization, and consistent messaging across channels during declared events.

Secondary Functions

Support periodic internal and external audits by compiling requested claim files, supporting schedules, and corrective action plans.
Collaborate with underwriting and risk management to feed back loss patterns, coverage disputes, or problematic endorsements that influence future underwriting guidelines.
Assist in the development and maintenance of claims procedures, playbooks and training materials to reflect regulatory changes and operational improvements.
Participate in cross-functional initiatives with IT to test claims system enhancements, validate business rules, and report defects during UAT.
Provide ad-hoc reporting support to leadership by extracting claims data, building pivot analyses in Excel, and highlighting top drivers of claim costs.
Serve as a point of contact for broker or client-specific account programs, performing periodic account reviews and implementing service level commitments.

Required Skills & Competencies

Hard Skills (Technical)

Claims adjudication and file management in commercial or personal lines (auto, property, liability, medical, workers’ compensation).
Strong knowledge of policy interpretation, coverages, endorsements, limits, and exclusions across P&C and/or health plans.
Proficiency with claims management systems (e.g., Guidewire ClaimCenter, Duck Creek, CCC One, Xactimate, claims portals) and common CRM tools.
Experience with medical billing and coding basics (ICD-10, CPT), EOB/EOB reconciliation, CPT/ICD review, and familiarity with UB-04 or CMS forms where applicable.
Hands-on experience with EDI claims transactions and remittance processes (837/835) and reconciling electronic payments.
Ability to set and manage claim reserves, perform loss projection logic, and document reserving rationale in the claims system.
Familiarity with subrogation and recovery processes, including lien management and salvage valuation.
Solid Excel skills (VLOOKUP, pivot tables, basic formulas) and the ability to run queries or extracts; basic SQL or data-query familiarity preferred.
Knowledge of regulatory and compliance requirements such as HIPAA (medical claims), state insurance code, and privacy/data protection standards.
Experience conducting fraud screening, identifying red flags, and coordinating with SIU or external investigators.
Strong documentation skills and the ability to prepare legal-compliant file notes, litigation packets, and discovery materials.
Comfortable using digital collaboration tools (SharePoint, Teams, Slack) and participating in remote claim review workflows.

Soft Skills

Exceptional attention to detail and accuracy in a high-volume, deadline-driven environment.
Strong verbal and written communication skills; able to explain technical coverage decisions clearly to non-technical stakeholders.
Customer-first mindset with empathy for claimants while protecting company interests and mitigating exposure.
Analytical problem-solving skills with the ability to synthesize multiple data sources and arrive at reasoned decisions.
Conflict resolution and negotiation skills to settle claims effectively and reduce potential litigation.
Time management and prioritization aptitude to balance simultaneous open files and meet SLAs.
Team collaboration and coaching ability to work across functions and mentor less-experienced colleagues.
Adaptability to changing business rules, emergent catastrophes, and periodic system upgrades.
Ethical judgment and professional integrity when handling sensitive claimant and medical data.
Resilience under pressure and focus on continuous improvement through feedback and metrics.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED; equivalent combination of relevant work experience and certifications considered.

Preferred Education:

Associate’s or Bachelor’s degree in Insurance, Risk Management, Business Administration, Healthcare Administration, or related field.

Relevant Fields of Study:

Insurance, Risk Management, or Actuarial Science
Business Administration or Management
Healthcare Administration or Medical Billing
Legal Studies or Paralegal (for complex liability files)

Experience Requirements

Typical Experience Range:

1–5 years of hands-on claims processing or claims support experience; entry-level candidates with strong training and certification may be considered.

Preferred:

3+ years of claims adjudication experience in the applicable line(s) of business (Personal Lines, Commercial, Auto, Property, Medical/Health, or Workers’ Compensation).
Prior experience with a major claims system (Guidewire, Duck Creek, CCC) and demonstrable track record of meeting KPIs (cycle time, accuracy, reserve accuracy).
Professional certifications such as AIC (Associate in Claims), CPCU, or insurance industry credentials are a plus.