Claims Examiner - Workers Compensation Job Description

Claims Examiners

A claims examiner is a person who processes applications for monetary compensation. A claims examiner's job is to either deny or reward a claim. An examiner must have the skills to determine if a claim should be rewarded and understand the red flags associated with fraudulent claims.

Investigating a claim is like solving a mystery. The claims examiner has the responsibility of determining if a claim is legitimate and if the person who placed it is giving the correct information. The examiner can identify people who need help from people who want to misuse the system.

Reviewing documentation and private investigation are two of the main jobs of a claims examiner. A claims examiner may need to place an individual under observation to get a better look at the situation. Many companies need qualified people to be claims examiners in the insurance and workers compensation areas.

Many examiners are responsible for keeping cost down because they have a keen awareness of the company's policies and can determine if a claim should be rewarded. In some cases, a claims examiner must acquire certification to be able to review claims and understand when fraudulent activity is taking place. The examiner must have a good knowledge of their field.

A claims examiner for a medical insurance company must understand different medical conditions. They must understand what medical records are critical to the investigation and how a physical condition can be legitimized. In some cases, a claims examiner is responsible for identifying asset misappropriation.

Health Insurance Examiners

The Bureau of Labor Statistics says that the industry will grow the most in health insurance in the next 20 years, as medical costs rise and federal mandates will require people to buy coverage. There is a claims examiner role. The role of claims examiners is to review the submissions of other claims professionals.

After the claims are submitted, examiners look at the documentation to make sure the claims follow company guidelines. In large cases that involve potential major financial payouts for insurers, examiners are called in. Monster notes that claims examiners look at questionable claims to determine whether payment is justified.

Examiners roles are different by company. Examiners who work for health insurers look at costs while life insurance examiners look at causes of death. To make sure insurance companies have enough money to pay claims, examiners study, adjust or make recommendations on cash reserves.

Examiners look for serious conditions or illnesses that pose high risks for the insurer. Administrative tasks are part of the job for claims examiners. They enter their claims into the company's computer systems.

They keep records of settled claims and have inventories of claims that need further analysis. They check and analyze data the company uses to settle claims, and then try to prove that claims are valid and payments are based on company practices and procedures. The claims examiners work with more than just computers, data sets and internal company investigators.

The Coal Mines Claims Examiner

The office is to provide black lung benefits and medical treatment coverage to coal miners who have been totally disabled by chronic dust disease of the lungs arising out of employment in the Nation's coal mines, as well as to provide benefits to the survivors of coal miners who died from the disease. Technical assistance is provided in the development of evidence. The person selected will be responsible for resolving complaints from subordinates and referring unresolved complaints to a higher level authority. The incumbent will give policy guidance and direction to the claims examiners for resolving novel or precedent setting issues, controversial interpretation of law, peculiar medical phenomena and for developmental purposes.