What does a Claims Service Representative do?
Claims service representatives evaluate customer insurance claims. Their tasks in this career include interviewing witnesses or customers and visiting accident sites to assess the scope of the claim. Also, they determine whether it is worth arranging a settlement and make sure all settlement claims are managed quickly. In addition to evaluating accidents and claims, they renew customer policies based on their history. Qualifications for the job include a firm knowledge of overall company policy, computer literacy, and excellent customer service.
Claims service representative responsibilities
Here are examples of responsibilities from real claims service representative resumes:
- Investigate, evaluate, and manage call to complete coverage analysis confirming or denying coverage using Xactimate estimating software.
- Experience in medical terminology, ICD9, CPT and DRG coding.
- Review types of service on claims base on the CPT codes and diagnosis code.
- Examine injure persons and administer first aid or cardiopulmonary resuscitation, if necessary, using training and medical supplies and equipment.
- Coordinate EDI traffic with external clearinghouses and business partner Multiplan.
- Process EDI reports, purge reports, and smart data reject list.
- Maintain disability files with pertinent client information according to HIPAA privacy rules throughout the disability process.
Claims service representative skills and personality traits
We calculated that 12% of Claims Service Representatives are proficient in Insurance Claims, Customer Service, and Policy Coverage. They’re also known for soft skills such as Computer skills, Customer-service skills, and Listening skills.
We break down the percentage of Claims Service Representatives that have these skills listed on their resume here:
- Insurance Claims, 12%
Assisted medical review department with provider and member authorization requests and appeals for health insurance claims processing.
- Customer Service, 11%
Utilized numerous computer systems simultaneously to provide quick and efficient service, while maintaining an above average customer service rating score.
- Policy Coverage, 8%
Verified accident facts and reviewed policy coverage to determine legal liability of automobile claims.
- Phone Calls, 7%
Serviced telephone calls and written correspondence received from providers and members.
- Claims Process, 6%
Provided administrative and supervisory support to the Claims Processing Supervisor.
- Inbound Calls, 4%
Handled inbound calls from policyholders and claimants reporting accidents, completed initial reports, and ensuring rapid and fair claim handling.
Common skills that a claims service representative uses to do their job include "insurance claims," "customer service," and "policy coverage." You can find details on the most important claims service representative responsibilities below.
Customer-service skills. Another essential skill to perform claims service representative duties is customer-service skills. Claims service representatives responsibilities require that "representatives help companies retain customers by professionally answering questions and helping to resolve complaints." Claims service representatives also use customer-service skills in their role according to a real resume snippet: "provided outstanding customer service regarding insurance claims"
Listening skills. This is an important skill for claims service representatives to perform their duties. For an example of how claims service representative responsibilities depend on this skill, consider that "representatives must listen carefully to ensure that they understand customers in order to assist them." This excerpt from a resume also shows how vital it is to everyday roles and responsibilities of a claims service representative: "answered telephone calls politely and respond courteously to routine questions, while applying effective listening skills to recognize customer needs. ".
Patience. claims service representative responsibilities often require "patience." The duties that rely on this skill are shown by the fact that "representatives should be patient and polite, especially when interacting with dissatisfied customers." This resume example shows what claims service representatives do with patience on a typical day: "exercise patience and control when dealing with escalated calls.assist force-load with attendance, incoming calls and manager callbacks. "
Problem-solving skills. A commonly-found skill in claims service representative job descriptions, "problem-solving skills" is essential to what claims service representatives do. Claims service representative responsibilities rely on this skill because "representatives must determine solutions to customers’ problems." You can also see how claims service representative duties rely on problem-solving skills in this resume example: "negotiated and resolved automobile insurance claims by phone. "
Interpersonal skills. Another skill commonly found on claims service representative job descriptions is "interpersonal skills." It can come up quite often in claims service representative duties, since "representatives should be able to create positive interactions with customers." Here's an example from a resume of how this skill fits into day-to-day claims service representative responsibilities: "organize, interpersonal and communication typing and input of information to computer system"
The three companies that hire the most claims service representatives are:
- GEICO65 claims service representatives jobs
- AAA Northeast37 claims service representatives jobs
- AmeriHealth Caritas9 claims service representatives jobs
Choose from 10+ customizable claims service representative resume templates
Build a professional claims service representative resume in minutes. Our AI resume writing assistant will guide you through every step of the process, and you can choose from 10+ resume templates to create your claims service representative resume.
Compare different claims service representatives
Claims service representative vs. Claims clerk
Claims clerks review the forms and documents for insurance claims to check for missing information and attachments. The data they obtain is entered into their database for safekeeping and quick retrieval. They should know the answers to their clients' questions about the regulations, policies, and procedures covered by their insurance policy. These clerks prepare documents that their agents use to present to their clients. When working for this position, a person must have the ability to communicate well and be familiar with computer applications.
There are some key differences in the responsibilities of each position. For example, claims service representative responsibilities require skills like "policy coverage," "phone calls," "claims process," and "auto accidents." Meanwhile a typical claims clerk has skills in areas such as "data entry," "clerical support," "shipping receiving," and "process claims." This difference in skills reveals the differences in what each career does.
On average, claims clerks reach similar levels of education than claims service representatives. Claims clerks are 1.6% less likely to earn a Master's Degree and 0.2% more likely to graduate with a Doctoral Degree.Claims service representative vs. Service associate
A service associate's role is to assist customers either through phone or in person. One of the service associate's primary responsibilities is to attain customer satisfaction by answering queries, performing troubleshooting methods, assisting in navigating through difficult tasks, handling complaints, resolving issues, and even processing payments. Furthermore, a service associate needs to be equipped with good communication skills to build rapport with clients as there are instances where they have to sell products and services.
While some skills are similar in these professions, other skills aren't so similar. For example, resumes show us that claims service representative responsibilities requires skills like "insurance claims," "policy coverage," "phone calls," and "claims process." But a service associate might use other skills in their typical duties, such as, "sales floor," "patients," "quality customer service," and "basic math."
Service associates earn similar levels of education than claims service representatives in general. They're 1.4% more likely to graduate with a Master's Degree and 0.2% more likely to earn a Doctoral Degree.Claims service representative vs. Representative
Representatives are lawmakers who represent the people in a specific district. They run for office to represent their districts in their hometown or their current place of living. Representatives are usually charismatic and good communicators. These characteristics are especially important during campaign and election periods. Representatives should be able to capture the hearts of the voters through their planned projects and advocacies. They are then elected by their constituents. Upon election, representatives author bills that will eventually be passed into law should it be approved by the majority of the congress. They also vote on the passage of bills authored by other representatives. They also participate in discussions and debates regarding different bills, issues, and laws. Representatives are expected to vote according to their conscience and in consideration of the voice of their constituents.
The required skills of the two careers differ considerably. For example, claims service representatives are more likely to have skills like "policy coverage," "phone calls," "claims process," and "auto accidents." But a representative is more likely to have skills like "cleanliness," "patients," "customer issues," and "data entry."
Representatives earn the highest salary when working in the transportation industry, where they receive an average salary of $36,557. Comparatively, claims service representatives have the highest earning potential in the government industry, with an average salary of $38,986.Most representatives achieve a similar degree level compared to claims service representatives. For example, they're 1.6% more likely to graduate with a Master's Degree, and 1.0% more likely to earn a Doctoral Degree.Claims service representative vs. Phone representative
A Phone Representative answers customer calls, complaints, and inquiries professionally. They handle and resolve customer complaints related to its services/products and product/service sales. Besides processing applications, orders, and forms requested by customers, Phone Representatives also update customers about the products/services information. These professionals record customer complaints, inquiries, feedback, and actions taken. They develop and maintain mutually beneficial and professional relationships with each customer. Moreover, they create and maintain cordial relationships with all new customers.
Even though a few skill sets overlap between claims service representatives and phone representatives, there are some differences that are important to note. For one, a claims service representative might have more use for skills like "insurance claims," "policy coverage," "phone calls," and "claims process." Meanwhile, some responsibilities of phone representatives require skills like "inbound phone calls," "troubleshoot," "financial transactions," and "alumni. "
Phone representatives enjoy the best pay in the health care industry, with an average salary of $49,071. For comparison, claims service representatives earn the highest salary in the government industry.In general, phone representatives hold similar degree levels compared to claims service representatives. Phone representatives are 2.3% less likely to earn their Master's Degree and 0.2% less likely to graduate with a Doctoral Degree.Types of claims service representative
Updated January 8, 2025
