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Become A Health Claims Examiner

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Working As A Health Claims Examiner

  • Getting Information
  • Resolving Conflicts and Negotiating with Others
  • Interacting With Computers
  • Communicating with Supervisors, Peers, or Subordinates
  • Identifying Objects, Actions, and Events
  • Unpleasant/Angry People

  • Mostly Sitting

  • Repetitive

  • Make Decisions

  • $74,350

    Average Salary

What Does A Health Claims Examiner Do At Allegiance Benefit Plan Management

* The Claims Examiner is responsible for the accurate and timely processing of medical, dental, vision and prescription drug claims.
* The incumbent is expected to provide courteous and prompt responses to customer inquiries.
* The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.
* ESSENTIAL JOB FUNCTIONS: Essential job functions include the following.
* Other functions may be assigned as business conditions change.
* Verifies the accuracy and receipt of all required documentation for each claim submitted.
* Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim.
* Analyzes information necessary for processing.
* This includes, but is not limited to, general participant and provider information, managed care affiliation, diagnosis codes, dates, place, type of service, procedure codes, and charges.
* Assures that the system processes the claim correctly and determines payment according to the plan as written.
* Word-processes correspondence to plan participants and providers in reference to pre-determinations and in response to basic benefit questions.
* Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries.
* Resolves problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims.
* Assigns critically ill patients to large case management.
* Assists the case manager with direct negotiation and the efficient use of benefits.
* Assists other examiners as needed due to workload requirements, including assigned back-up when examiners are absent.
* Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review.
* Researches, calculates and requests refunds when necessary.
* Contributes to the daily workflow with regular and punctual attendance.
* Thoroughly researches and completes renewal reports in a timely manner in consultation with the Marketing Department.
* Process eligible claims on groups before the end of their stoploss contract renewal

What Does A Health Claims Examiner Do At West Corporation

* Providing assistance to member's questions relating to medical claims cost negotiation
* Tracking all settlements throughout the claims process on claims details screen, achieving highest savings possible
* Ensure settlement results are updated in department databases accurately and communicate each case outcome and statistics to management

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How To Become A Health Claims Examiner

A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster, examiner, or investigator. Higher level positions may require a bachelor’s degree or some insurance-related work experience. Auto damage appraisers typically have either a postsecondary nondegree award or work experience in identifying and estimating the cost of automotive repair.


A high school diploma or equivalent is typically required for a person to work as an entry-level claims adjuster, examiner, or investigator. However, employers sometimes prefer to hire applicants who have a bachelor’s degree or some insurance-related work experience or vocational training. Auto damage appraisers typically have either a postsecondary nondegree award or experience working in an auto repair shop, identifying and estimating the cost of automotive repair.

The varying types of work in these occupations can require different backgrounds or different college coursework. For example, a business or an accounting background might be best for someone who wishes to specialize in claims of financial loss due to strikes, equipment breakdowns, or merchandise damage. College training in architecture or engineering is helpful for adjusting industrial claims, such as those involving damage from fires or other accidents. A legal background is beneficial to someone handling workers’ compensation and product liability cases. A medical background is useful for examiners working on medical and life insurance claims.

Although auto damage appraisers are not required to have a college education, most companies prefer to hire people who have the formal training, experience, or knowledge and technical skills to identify and estimate the cost of automotive repair. Many vocational schools and some community colleges offer programs in auto body repair and teach students how to estimate the cost of repairing damaged vehicles.

For investigator jobs, a high school diploma or equivalent is the typical education requirement. Most insurance companies prefer to hire people trained as law enforcement officers, private investigators, claims adjusters, or examiners, because these workers have good interviewing and interrogation skills.


At the beginning of their careers, claims adjusters, examiners, and investigators work on small claims, under the supervision of an experienced worker. As they learn more about claims investigation and settlement, they are assigned larger, more complex claims.

Auto damage appraisers typically get on-the-job training, which may last several months. This training usually involves working under the supervision of a more experienced appraiser while estimating damage costs, until the employer decides that the trainee is ready to do estimates on his or her own.

Licenses, Certifications, and Registrations

Licensing requirements for claims adjusters, appraisers, examiners, and investigators vary by state. Some states have few requirements; others require either completing prelicensing education or receiving a satisfactory score on a licensing exam (or both).

In some states, claims adjusters employed by insurance companies do not have to become licensed themselves because they can work under the company license.

Public adjusters may need to meet separate or additional requirements.

Some states that require licensing also require a certain number of continuing education credits per year to renew the license. Federal and state laws and court decisions affect how claims must be handled and what insurance policies can and must cover. Examiners working on life and health claims must stay up to date on new medical procedures and the latest prescription drugs. Examiners working on auto claims must be familiar with new car models and the most recent repair techniques. In order to fulfill their continuing education requirements, workers can attend classes or workshops, write articles for claims publications, or give lectures and presentations.

Important Qualities

Analytical skills. Adjusters and examiners must both evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay. Adjusters must carefully consider various pieces of information to reach a decision.

Communication skills. Claims adjusters and investigators must get information from a wide range of people, including claimants, witnesses, and medical experts. They must know the right questions to ask in order to gather the information they need.

Detail oriented. Adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences.

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. These workers must be understanding, yet firm with their company’s policies.

Math skills. Appraisers must be able to calculate property damage.

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Health Claims Examiner Demographics


  • Female

  • Male

  • Unknown



  • White

  • Hispanic or Latino

  • Asian

  • Unknown

  • Black or African American

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Languages Spoken

  • Swedish

  • Thai

  • Spanish


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Top Skills for A Health Claims Examiner


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Top Health Claims Examiner Skills

  1. Customer Service
  2. Blood Pressure
  3. Medical Claims
You can check out examples of real life uses of top skills on resumes here:
  • Received several awards for providing excellent customer service.
  • Blood withdrawalsFinger sticksHeight/weight measurementsBMI measurementWaist measurementBlood pressure
  • process medical claims for payment or denial
  • Instructed classes of 6 - 18 students in the basics of Health Insurance Claims Processing.
  • Examine claims forms and other records to determine health insurance coverage and claims payment.

Top Health Claims Examiner Employers

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