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 representing typical tasks they are likely to perform in their roles.

  • 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 list "customer service," "quality standards," and "policy coverage" as skills on their resumes. We go into more details on the most important claims representative responsibilities here:

  • The most important skills for a claims representative to have in this position are analytical skills. In this excerpt that we gathered from a claims representative resume, you'll understand why: "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay" According to resumes we found, analytical skills can be used by a claims representative in order to "determined settlement value and analyzed the potential costs, benefits, and risk of litigation. "
  • While it may not be the most important skill, we found that many claims representative duties rely on detail oriented. This example from a claims representative explains why: "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences." This resume example is just one of many ways claims representatives are able to utilize detail oriented: "conducted detailed bill reviews to implement sound litigation management and expense control. "
  • Interpersonal skills is also an important skill for claims representatives to have. This example of how claims representatives use this skill comes from a claims representative resume, "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" Read this excerpt from a resume to understand how vital it is to their everyday roles and responsibilities, "utilized interpersonal skills for detailed explanation of insurance claims procedures and processes. "
  • A thorough review of lots of resumes revealed to us that "math skills" is important to completing claims representative responsibilities. This resume example shows just one way claims representatives use this skill: "appraisers must be able to calculate property damage." Here's an example of how this skill is used from a resume that represents typical claims representative tasks: "determined policy coverage by the usage of mathematical formulas and the review of policy rules and clauses. "
  • As part of the claims representative description, you might find that one of the skills that might be helpful to the job is "communication skills." A claims representative resume included this snippet: "claims adjusters and investigators must get information from a wide range of people, including claimants, witnesses, and medical experts" This skill could be useful in this scenario: "negotiated settlements with responsible parties through direct communications, arbitration, mediation and litigation. "
  • See the full list of claims representative skills.

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    What Property Adjusters Do

    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.

    In this section, we take a look at the annual salaries of other professions. Take property adjuster for example. On average, the property adjusters annual salary is $15,865 higher than what claims representatives make on average every year.

    While the salaries between these two careers can be different, they do share some of the same responsibilities. Employees in both claims representatives and property adjusters positions are skilled in customer service, policy coverage, and reservations.

    These skill sets are where the common ground ends though. A claims representative responsibility is more likely to require skills like "taking care," "judgment decision making," "quality standards," and "insurance policies." Whereas a property adjuster requires skills like "ladders," "strong analytical," "excellent interpersonal," and "property losses." Just by understanding these different skills you can see how different these careers are.

    Property adjusters receive the highest salaries in the insurance industry coming in with an average yearly salary of $58,634. But claims representatives are paid more in the government industry with an average salary of $45,430.

    The education levels that property adjusters earn is a bit different than that of 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.

    What Are The Duties Of an 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.

    The next role we're going to look at is the insurance adjuster profession. Typically, this position earns a higher pay. In fact, they earn a $18,519 higher salary than claims representatives per year.

    A similarity between the two careers of claims representatives and insurance adjusters are a few of the skills associated with both roles. We used resumes from both professions to find that both use skills like "customer service," "policy coverage," and "claims handling. "

    While some skills are similar in these professions, other skills aren't so similar. For example, several resumes showed us that claims representative responsibilities requires skills like "taking care," "judgment decision making," "quality standards," and "reservations." But an insurance adjuster might use skills, 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 side of things, claims representatives receive higher paychecks in the government industry where they earn an average of $45,430.

    On the topic of education, 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.

    How an Adjuster Compares

    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 adjuster profession generally makes a higher amount of money when compared to the average salary of claims representatives. The difference in salaries is adjusters making $10,600 higher than claims representatives.

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

    As mentioned, these two careers differ between other skills that are required for performing the work exceedingly well. For example, gathering from claims representatives resumes, they are more likely to have skills like "taking care," "judgment decision making," "quality standards," and "reservations." But a adjuster might 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. Whereas claims representatives are paid the highest salary in the government industry with the average being $45,430.

    Adjusters are known to earn similar educational levels when compared to claims representatives. Additionally, they're 0.6% more likely to graduate with a Master's Degree, and 0.2% more likely to earn a Doctoral Degree.

    Description Of an Appraiser

    Now, we'll look at appraisers, who generally average a higher pay when compared to claims representatives annual salary. In fact, the difference is about $3,427 per year.

    While their salaries may vary, claims representatives and appraisers both use similar skills to perform their jobs. Resumes from both professions include skills like "customer service," "claims handling," and "litigation. "

    Even though a few skill sets overlap, 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 appraisers might include skills like "appraisal reports," "mai," "discounted cash flow," and "market research" on their resume.

    Appraisers earn a higher salary in the insurance industry with an average of $48,145. Whereas, claims representatives earn the highest salary in the government industry.

    The average resume of appraisers showed that they earn similar levels of education to claims representatives. So much so that the likelihood of them earning a Master's Degree is 2.5% more. Additionally, they're more likely to earn a Doctoral Degree by 0.0%.

    What a Claims Representative Does FAQs

    How Much Does A Claims Representative Make?

    A claims representative makes, on average, $37,000 a year ($17.91 an hour). However, how much a claims representative can make ranges from as little as $26,000 to as much as $51,000 a year. Factors such as location and industry impact how much a claims representative can make.

    Is A Claims Rep The Same As An Adjuster?

    Yes, a claims rep is the same as an adjuster. Depending on the insurance company they work for, their job title might be Claims Representative, Claims Specialist, Claims Examiner, or Claims Investigator. But as a group, these claims professionals are commonly referred to as "claims adjusters."

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