What does a claims representative do?
A Claims Representative is an agent who works for insurance companies in order to investigate and settle claims. The agent acts as an intermediary between customers and insurance companies by evaluating the customers' facts surrounding claims and determining whether the loss is covered or should be compensated. Such a role is important because an agent makes sure that no fraud claims are being paid out. It is also highlighted that an agent works in compliance with state regulations.
Claims representative responsibilities
Here are examples of responsibilities from real claims representative resumes:
- Perform initial set-up and continuously manage claims in the Juris claims management system.
- Investigate, evaluate, and manage call to complete coverage analysis confirming or denying coverage using Xactimate estimating software.
- Prepare necessary state filings within statutory limits, manage litigation and vocational rehabilitation process, used appropriate cost containment techniques.
- Assist the training department in developing CSR training in order to set expectations.
- Create custom templates and guide sheets for new trainees in the CSR Internet division to ensure consistency and increase department efficiency.
- Utilize proper SIU reporting procedures for extensive investigation as required.
- Recognize for developing relationships with SIU and decreasing expenses while insuring appropriate payment.
- Review medical records to complete bodily injury evaluations and complete the negotiation of claims.
- Respond to time sensitive materials, including but not limit to inter-company arbitration hearings and departments of insurance complaints.
- Complete required claim forms for patients to request reimbursement for services render by both developmental pediatrician and psychology staff.
- Analyze claims to determine extent of patients insurance liability, review and negotiate settlements with claimants insurance policy provisions.
- Respond to arbitration hearings (inter-company mediation regarding liability) and file appropriate transcripts and paperwork on behalf of insure.
- Complete field inspection of losses including accurate scope of damages, photographic evidence collection, written estimates utilizing Xactimate estimating software.
- Establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition.
- Generate safety reports and observations with HAZMAT procedures and file all reports daily.
Claims representative skills and personality traits
We calculated that 26% of Claims Representatives are proficient in Customer Service, Quality Standards, and Policy Coverage. They’re also known for soft skills such as Analytical skills, Detail oriented, and Interpersonal skills.
We break down the percentage of Claims Representatives that have these skills listed on their resume here:
- Customer Service, 26%
Provided optimum customer service to policyholders; daily correspondence by phone and/or mail to ensure complete and accurate information about claims.
- Quality Standards, 6%
Processed physician claims according to members Certificate of Coverage while meeting specific production and quality standards.
- Policy Coverage, 6%
Obtained facts to evaluate coverage, negligence, medical necessity and Causation/damages to make proper liability and policy coverage decisions.
- Reservations, 5%
Composed professional communications including reservations of rights, status, settlement and declination letters.
- Claims Handling, 3%
Provided training on claims processes and successful customer relationship management skills, promoted adherence to internal and state-regulated claims handling standards.
- Insurance Coverage, 3%
Responded courteously and accurately to all phone inquiries regarding verification of members' insurance coverage, eligibility and claim status.
Most claims representatives use their skills in "customer service," "quality standards," and "policy coverage" to do their jobs. You can find more detail on essential claims representative responsibilities here:
Analytical skills. The most essential soft skill for a claims representative to carry out their responsibilities is analytical skills. This skill is important for the role because "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay." Additionally, a claims representative resume shows how their duties depend on analytical skills: "determined settlement value and analyzed the potential costs, benefits, and risk of litigation. "
Detail oriented. Many claims representative duties rely on detail oriented. "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences.," so a claims representative will need this skill often in their role. This resume example is just one of many ways claims representative responsibilities rely on detail oriented: "conducted detailed bill reviews to implement sound litigation management and expense control. "
Interpersonal skills. This is an important skill for claims representatives to perform their duties. For an example of how claims representative responsibilities depend on this skill, consider that "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 excerpt from a resume also shows how vital it is to everyday roles and responsibilities of a claims representative: "utilized interpersonal skills for detailed explanation of insurance claims procedures and processes. ".
Communication skills. Another crucial skill for a claims representative to carry out their responsibilities is "communication skills." A big part of what claims representatives relies on this skill, since "claims adjusters and investigators must get information from a range of people, including claimants, witnesses, and medical experts." How this skill relates to claims representative duties can be seen in an example from a claims representative resume snippet: "negotiated settlements with responsible parties through direct communications, arbitration, mediation and litigation. "
The three companies that hire the most claims representatives are:
- Sedgwick LLP265 claims representatives jobs
- The Independent Traveler230 claims representatives jobs
- The Travelers Companies148 claims representatives jobs
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Compare different claims representatives
Claims representative vs. Property adjuster
Typically working for insurance companies, a property adjuster specializes in inspecting property damages to assess and determine a company's financial obligations. Their responsibilities revolve around reaching out to clients through calls and correspondence, arranging appointments, gathering and verifying data, and traveling to different locations to meet with clients. They may also negotiate settlements and authorize payments in adherence to the company's policies and regulations. Furthermore, as a property adjuster, it is essential to have a deep understanding of property costs to ensure the accuracy of claims.
These skill sets are where the common ground ends though. The responsibilities of a claims representative are more likely to require skills like "taking care," "judgment decision making," "quality standards," and "insurance policies." On the other hand, a job as a property adjuster requires skills like "ladders," "strong analytical," "excellent interpersonal," and "property losses." As you can see, what employees do in each career varies considerably.
Property adjusters earn the highest salaries when working in the insurance industry, with an average yearly salary of $58,634. On the other hand, claims representatives are paid more in the government industry with an average salary of $45,430.The education levels that property adjusters earn slightly differ from claims representatives. In particular, property adjusters are 0.9% more likely to graduate with a Master's Degree than a claims representative. Additionally, they're 0.0% less likely to earn a Doctoral Degree.Claims representative vs. Insurance adjuster
An adjuster is responsible for evaluating the extent of loss in the company by calculating the damage costs, determining the settlement payment to the client, and managing the reputation of the company for claims accountability. Adjusters must have extensive knowledge of the insurance principles and processes, following the state and federal regulations to protect clients and the business from insurance fraud. They collect documents from different organizations, perform field research, and interview witnesses to verify the accuracy of claims statement.
While some skills are similar in these professions, other skills aren't so similar. For example, resumes show us that claims representative responsibilities requires skills like "taking care," "judgment decision making," "quality standards," and "reservations." But an insurance adjuster might use other skills in their typical duties, such as, "catastrophe claims," "public adjusters," "state farm insurance," and "property loss."
Insurance adjusters may earn a higher salary than claims representatives, but insurance adjusters earn the most pay in the insurance industry with an average salary of $60,583. On the other hand, claims representatives receive higher pay in the government industry, where they earn an average salary of $45,430.insurance adjusters earn similar levels of education than claims representatives in general. They're 1.2% more likely to graduate with a Master's Degree and 0.0% more likely to earn a Doctoral Degree.Claims representative vs. Adjuster
An appraiser is someone who assesses the monetary value of a property such as an automobile, real property, and personal claim. His/Her or her responsibilities include resolving disparities between a property's monetary values and preparing narrative reports for projects. The essential skills that an appraiser should possess to accomplish such responsibilities include a keen eye for details, strong communication, analytical, and problem-solving skills, and the ability to work under pressure. The education requirements for the job vary depending on the area of focus.
The required skills of the two careers differ considerably. For example, claims representatives are more likely to have skills like "taking care," "judgment decision making," "quality standards," and "reservations." But a adjuster is more likely to have skills like "strong customer service," "repair estimates," "catastrophe claims," and "general liability."
Adjusters make a very good living in the insurance industry with an average annual salary of $50,894. On the other hand, claims representatives are paid the highest salary in the government industry, with average annual pay of $45,430.adjusters typically earn similar educational levels compared to claims representatives. Specifically, they're 0.6% more likely to graduate with a Master's Degree, and 0.2% more likely to earn a Doctoral Degree.Claims representative vs. Appraiser
Even though a few skill sets overlap between claims representatives and appraisers, there are some differences that are important to note. For one, a claims representative might have more use for skills like "taking care," "judgment decision making," "quality standards," and "policy coverage." Meanwhile, some responsibilities of appraisers require skills like "appraisal reports," "mai," "discounted cash flow," and "market research. "
Appraisers enjoy the best pay in the insurance industry, with an average salary of $48,145. For comparison, claims representatives earn the highest salary in the government industry.The average resume of appraisers showed that they earn similar levels of education compared to claims representatives. So much so that theyacirc;euro;trade;re 2.5% more likely to earn a Master's Degree and more likely to earn a Doctoral Degree by 0.0%.Types of claims representative
Updated January 8, 2025
