What Does a Claim Specialist Do?

A claims specialist is responsible for processing insurance claims, reviewing insurance coverage, and analyzing claims cases. Claims specialists' duties include negotiating claims settlements, validating claims to prevent fraud, creating court testimonies as needed, developing claim review plans, and checking necessary documents and related resolve claims. A claims specialist must have strong analytical and critical-thinking skills to authorize claim payment and investigate complex and unusual claims. Claims specialists should also have extensive knowledge of the insurance processes to handle various cases, following legal policies and regulatory procedures.

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Claim Specialist Responsibilities

Here are examples of responsibilities from real claim specialist resumes representing typical tasks they are likely to perform in their roles.

Assist in the streamlining of EDI process to manage workflow of EDI claims.
Manage claims on desk, route/queues, and ECHS within specify turn-around-time parameters.
Manage claims, route/queues, and ECHS, within specify turn- around time parameters.
Investigate, manage, negotiate and resolve claims arising out of accidents involving automobile and homeowner policies.
Upgrade CPT-4 and ICD-9 coding procedures, staying in step with many manage care plans changing reimbursement schedules.
Manage expedition of appeals via problem solving and collaboration with other departments.
Provide administrative assistance taking dictation, handling telephone calls, set up meetings.
Train on both ACAS and HMO platforms.
Coordinate with insurance companies on insurance claims; and resolve millions of dollars in balances - Sr.
Handle and dispose of claims in litigation by preparing and developing strategy with defense counsel and consensus relative to litigation handling.
Present evaluations and status reports to Sr.
Verify all member and provider information is correct and also make sure all HCPCS codes are correct
Process all inpatient and skill nursing claims with correct DRG and CSM codes to paid allowable amount.
Used windows base system to access client information for loss assessments, post and reassign claims to adjusters.
Verify post billing edits to ensure correct coding bill unit amounts and CPT codes to ensure clean claim submission.

Claim Specialist Job Description

Between the years 2018 and 2028, claim specialist jobs are expected to undergo a growth rate described as "decline" at -4%, according to the Bureau of Labor Statistics. So if the thought "should I become a claim specialist?" Has crossed your mind, maybe you should take the growth rate into account. In addition, the number of claim specialist opportunities that are projected to become available by 2028 is -13,000.

On average, the claim specialist annual salary is $43,164 per year, which translates to $20.75 an hour. Generally speaking, claim specialists earn anywhere from $27,000 to $67,000 a year, which means that the top-earning claim specialists make $43,000 more than the ones at the lower end of the spectrum.

Once you've become a claim specialist, you may be curious about what other opportunities are out there. Careers aren't one size fits all. For that reason, we discovered some other jobs that you may find appealing. Some jobs you might find interesting include a medical claims examiner, senior claims examiner, senior claims representative, and senior claims adjuster.

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12 Claim Specialist Resume Examples

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Judy Myers Claim Specialist Contact Information Main, PA (950) 555-3585 jmyers@example.com Skills REP Quality Standards DMV New Insurance Policies Loss Reports Retrieve Information Adjusters Claims Processing Guidelines Delinquent Accounts Profitable Business Employment History Claim Specialist 2013 - Present Social Security Administration Main, PA Implemented HIPAA guidelines when obtaining medical records. Research Medicare or Medicaid program issues and develop appropriate responses that include citation of regulations, policy issuances and guidance. Maintain ongoing communication with other departments and management. Claim Processing Specialist 2012 - 2013 Allstate Main, PA Processed auto claims and worked directly with priority repair facilities in processing customer claims in a timely and efficient manner. Process moderately complex non technical auto claims while maintaining positive relationships with customers in an inbound/outbound claim center. Prepared arbitration packages for Arbitration Forum, ensuring effective communication and clarity of data. Created training materials and trained processors on state insurance compliance laws & policy coverage guidelines. Handled OAD tasks, issued Eagle View payments and validated Large Loss claims. Insurance Assistant 2009 - 2011 Allstate Main, PA Completed many hours of cold calling to obtain new customers. Write insurance policies for new customers. Received cash and checks receipts, maintained ledger book and computer record of bank deposits. Obtained medical records from providers. Ordered Loss Runs Reports and prepared Loss Summaries. Education Master's Degree Business 2011 - 2012 Pennsylvania State University Main, PA Bachelor's Degree Business 2006 - 2009 Pennsylvania State University Main, PA


Jonathan Young Claim Specialist Contact Info Olathe, KS (870) 555-4778 jyoung@example.com Skills Necessary InformationInsurance CompaniesClaims DepartmentEnsure AccuracyCommunicationQuality StandardsTelephone CallsInsurance PolicyClaims InformationPertinent Information Employment History Claim Specialist 2020 - Present Farmers Insurance Olathe, KS Worked with management to update KPIs and advancement tests for claims adjusters. Adjusted commercial and residential property insurance claims for several insurance companies and independent contractors. Contacted and interviewed claimants, experts, law enforcement personnel and medical specialists to obtain additional information. Recovered over-payments and unpaid claims and processed for payment if necessary Participated in special projects as assigned by supervisor. Claims Representative 2010 - 2020 Wells Fargo Colorado Springs, CO Prepared "Guarantee of Title" for insurance companies upon request for payoff on vehicles. Review loans for appropriate documentation and complete regular follow up with foreclosure attorneys, internal departments and others for missing information. Insure customer satisfaction by providing the most complete and accurate service as possible while maintaining company policies. Partnered with support staff to create and evaluate department processes and procedures. Reviewed policy coverage to determine eligibility and documented/processed personal injury protection claims with minimal managerial assistance. Claims Service Representative 2008 - 2010 Wells Fargo Colorado Springs, CO Maintain personal and branch sales goals Deal with daily customer service issues All types of bank teller work Assess customer needs, suggest and promote other helpful bank products and services and refer to appropriate area. Open member services daily mail and hand/deliver accordingly. Education Bachelor's Degree Business 2005 - 2008 Colorado Technical University Colorado Springs, CO


Jose Edwards Claim Specialist New Albany, OH (530) 555-8926 jedwards@example.com Experience Claim Specialist2013 - Present Aetna•New Albany, OH Coordinate benefits with Medicare and Medicaid. Research claim information to properly process claims. Faxed clinicals to insurance companies for review in order for them to make a determination of a request. Claim Specialist2011 - 2013 Aetna•New Albany, OH Received several awards for having met or exceeded our quality standards. Investigate, evaluate, and settle insurance claims Determine whether Aetna's policy covered the Medicare claim presented. Bill claims to patients' primary, secondary and tertiary insurance companies. Contacted insurance companies to check status of claim payments. Medical Claims Examiner2010 - 2011 Aetna•New Albany, OH Requested medical records from providers and personal information from claimants. Contacted health care providers to obtain clinical information and paperwork required to process and complete claims. Adjudicated HMO/PPO, Medicare and Medicaid claims; processed Stop-Loss claims. Processed medical and dental claims for various sponsors & corporate Accounts, including UPS, USM Corp. and Tyco International. Determined proper policy coverage and concluded cases according to company guidelines in a timely fashion. Skills Loss ReportsIcd-9Medical RecordsPertinent InformationProperty DamageAdjudicate ClaimsLaw EnforcementBlood PressureHealth ScreeningsPIP Education Bachelor's Degree Criminal Justice2007 - 2010 University of Cincinnati•Cincinnati, OH

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Claim Specialist Skills and Personality Traits

We calculated that 19% of Claim Specialists are proficient in Customer Service, Litigation, and Patients. They’re also known for soft skills such as Analytical skills, Detail oriented, and Math skills.

We break down the percentage of Claim Specialists that have these skills listed on their resume here:

Customer Service, 19%
Provided exemplary and timely customer service, immediately confirming coverage or effectively identifying and promptly addressing any gaps in coverage.
Litigation, 7%
Handled and disposed of claims in litigation by preparing and developing strategy with defense counsel and consensus relative to litigation handling.
Patients, 5%
Completed required claim forms for patients to request reimbursement for services rendered by both developmental pediatrician and psychology staff.
Claims Handling, 4%
Possessed homeowner & auto policy knowledge and applies appropriately to claims handling to determine coverage if necessary on customer inquiries.
Quality Standards, 4%
Answered questions within the department and relayed information to the Claims Supervisor regarding individual reports reflecting daily production and quality standards.
Excellent Organizational, 4%
Detail oriented with excellent organizational skills.

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Some of the skills we found on claim specialist resumes included "customer service," "litigation," and "patients." We have detailed the most important claim specialist responsibilities below.

Analytical skills can be considered to be the most important personality trait for a claim specialist to have. According to a claim specialist resume, "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay" claim specialists are able to use analytical skills in the following example we gathered from a resume: "solved complex problems involving coverage, liability, risk analysis, investigations, and litigation management. "

Another commonly found skill for being able to perform claim specialist duties is the following: detail oriented. According to a claim specialist resume, "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences." Check out this example of how claim specialists use detail oriented: "prepared customer correspondence and detailed reports for litigation to ensure the gathering of critical information and adherence to company guidelines. "

Another skill that is quite popular among claim specialists is math skills. This skill is very critical to fulfilling every day responsibilities as is shown in this example from a claim specialist resume: "appraisers must be able to calculate property damage." This example from a resume shows how this skill is used: "assist in subrogation process investigate claims, perform mathematical calculations for salvagevalue, medical billing and property damage. "

A thorough review of lots of resumes revealed to us that "communication skills" is important to completing claim specialist responsibilities. This resume example shows just one way claim specialists use this skill: "claims adjusters and investigators must get information from a wide range of people, including claimants, witnesses, and medical experts" Here's an example of how this skill is used from a resume that represents typical claim specialist tasks: "command of written and verbal communication skills for contact and/or negotiation and litigation. "

Yet another important skill that a claim specialist must demonstrate is "interpersonal skills." Adjusters, examiners, and investigators often meet with claimants and others who may be upset by the situation that requires a claim or by the settlement the company is offering This is clearly demonstrated in this example from a claim specialist who stated: "contribute to a team environment by maintaining excellent interpersonal skills and demonstrating flexibility with daily operations/functions. "

See the full list of claim specialist skills.

After discovering the most helpful skills, we moved onto what kind of education might be helpful in becoming a claim specialist. We found that 54.4% of claim specialists have graduated with a bachelor's degree and 5.4% of people in this position have earned their master's degrees. While most claim specialists have a college degree, you may find it's also true that generally it's possible to be successful in this career with only a high school degree. In fact, our research shows that one out of every six claim specialists were not college graduates.

The claim specialists who went onto college to earn a more in-depth education generally studied business and criminal justice, while a small population of claim specialists studied health care administration and psychology.

Once you've obtained the level of education you're comfortable with, you might start applying to companies to become a claim specialist. We've found that most claim specialist resumes include experience from Zurich, Sedgwick LLP, and Expeditors. Of recent, Zurich had 149 positions open for claim specialists. Meanwhile, there are 119 job openings at Sedgwick LLP and 93 at Expeditors.

If you're interested in companies where claim specialists make the most money, you'll want to apply for positions at W. R. Berkley, Chubb, and BERKLEY TECHNOLOGY SERVICES. We found that at W. R. Berkley, the average claim specialist salary is $99,721. Whereas at Chubb, claim specialists earn roughly $92,513. And at BERKLEY TECHNOLOGY SERVICES, they make an average salary of $92,508.

View more details on claim specialist salaries across the United States.

We also looked into companies who hire claim specialists from the top 100 educational institutions in the U.S. The top three companies that hire the most from these institutions include State Farm, Nationwide, and Allstate.

The three companies that hire the most prestigious claim specialists are:

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What Medical Claims Examiners Do

A medical claims examiner determines whether an insurer will be covering losses from accidents and illness. They are responsible for evaluating insurance claims and applications, following up with insurance adjusters to protect an insurer from financial loss, ensuring information integrity, and ensuring standard guidelines are adhered to. They are also tasked with approving payment and facilitating additional investigation. Qualifications for this position include knowledge of medical terminology.

In this section, we compare the average claim specialist annual salary with that of a medical claims examiner. Typically, medical claims examiners earn a $391 lower salary than claim specialists earn annually.

While their salaries may differ, one common ground between claim specialists and medical claims examiners are a few of the skills required in each craft. In both careers, employees bring forth skills like customer service, claims handling, and quality standards.

There are some key differences in responsibilities as well. For example, a claim specialist responsibilities require skills like "litigation," "patients," "excellent organizational," and "excellent interpersonal." Meanwhile a typical medical claims examiner has skills in areas such as "medical treatment," "provider contracts," "cpt-4," and "process claims." This difference in skills reveals how truly different these two careers really are.

Medical claims examiners really shine in the technology industry with an average salary of $52,782. Whereas claim specialists tend to make the most money in the insurance industry with an average salary of $56,779.

On average, medical claims examiners reach similar levels of education than claim specialists. Medical claims examiners are 2.1% less likely to earn a Master's Degree and 0.8% less likely to graduate with a Doctoral Degree.

What Are The Duties Of a Senior Claims Examiner?

Senior claims examiners review, assess, and process the insurance claims of their clients. The examiners provide recommendations for claims-related resolution. It is their responsibility to examine and authorize the investigation of insurance claims as conducted by insurance adjusters. They check the claims and the insurance policies to ensure that all the information is right. During the settlement, they are expected to be careful in keeping the records with details of the process.

The next role we're going to look at is the senior claims examiner profession. Typically, this position earns a higher pay. In fact, they earn a $7,798 higher salary than claim specialists per year.

Not everything about these jobs is different. Take their skills, for example. Claim specialists and senior claims examiners both include similar skills like "customer service," "litigation," and "claims handling" on their resumes.

In addition to the difference in salary, there are some other key differences that are worth noting. For example, claim specialist responsibilities are more likely to require skills like "patients," "excellent organizational," "excellent interpersonal," and "data entry." Meanwhile, a senior claims examiner might be skilled in areas such as "property damage," "tpa," "medical management," and "medical treatment." These differences highlight just how different the day-to-day in each role looks.

It's been discovered that senior claims examiners earn higher salaries compared to claim specialists, but we wanted to find out where senior claims examiners earned the most pay. The answer? The finance industry. The average salary in the industry is $92,671. Additionally, claim specialists earn the highest paychecks in the insurance with an average salary of $56,779.

In general, senior claims examiners study at similar levels of education than claim specialists. They're 0.1% less likely to obtain a Master's Degree while being 0.8% more likely to earn a Doctoral Degree.

How a Senior Claims Representative Compares

A senior claims representative serves as a client's primary point of contact when processing insurance claims. Their responsibilities include meeting with clients to identify their needs, gathering and verifying documentation, conducting investigations to determine the validity of insurance claims, liaising with external parties, and negotiating the amount of compensation. Furthermore, as a senior claims representative, it is essential to lead and serve as a mentor to junior claims representatives, all while implementing the company's policies and regulations, including its vision and mission.

The third profession we take a look at is senior claims representative. On an average scale, these workers bring in higher salaries than claim specialists. In fact, they make a $11,428 higher salary per year.

By looking over several claim specialists and senior claims representatives resumes, we found that both roles utilize similar skills, such as "customer service," "litigation," and "claims handling." But beyond that the careers look very different.

There are many key differences between these two careers as shown by resumes from each profession. Some of those differences include the skills required to complete responsibilities within each role. As an example of this, a claim specialist is likely to be skilled in "patients," "quality standards," "excellent organizational," and "medical terminology," while a typical senior claims representative is skilled in "automobile claims," "claims process," "coverage analysis," and "sr."

Senior claims representatives are known to earn similar educational levels when compared to claim specialists. Additionally, they're 0.7% less likely to graduate with a Master's Degree, and 0.0% less likely to earn a Doctoral Degree.

Description Of a Senior Claims Adjuster

A senior claims adjuster is in charge of inspecting and analyzing insurance claims to validate and adjust payments. Among their responsibilities include reviewing and verifying claims documents, visiting sites to investigate property damages and personal injuries, gathering evidence such as photos and videos, and conducting interviews with witnesses and clients. Moreover, as a senior claims adjuster, it is essential to lead and serve as a mentor to fellow claims adjusters while enforcing and promoting the company's policies and regulations.

Now, we'll look at senior claims adjusters, who generally average a higher pay when compared to claim specialists annual salary. In fact, the difference is about $15,524 per year.

While both claim specialists and senior claims adjusters complete day-to-day tasks using similar skills like customer service, litigation, and claims handling, the two careers also vary in other skills.

Each job requires different skills like "patients," "quality standards," "excellent organizational," and "excellent interpersonal," which might show up on a claim specialist resume. Whereas senior claims adjuster might include skills like "strong customer service," "settlement authority," "litigation management," and "state regulations."

Now, let's take a closer look at the financials in each career. The insurance industry tends to pay more for senior claims adjusters with an average of $66,103. While the highest claim specialist annual salary comes from the insurance industry.

In general, senior claims adjusters reach similar levels of education when compared to claim specialists resumes. Senior claims adjusters are 0.6% more likely to earn their Master's Degree and 0.5% more likely to graduate with a Doctoral Degree.

Updated October 2, 2020