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Become A Medical Claims Examiner

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Working As A Medical 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

  • $68,494

    Average Salary

What Does A Medical Claims Examiner Do

Claims adjusters, appraisers, examiners, and investigators evaluate insurance claims. They decide whether an insurance company must pay a claim and, if so, how much.

Duties  

Claims adjusters, appraisers, examiners, and investigators typically do the following:

  • Investigate, evaluate, and settle insurance claims
  • Determine whether the insurance policy covers the loss claimed
  • Decide the appropriate amount the insurance company should pay
  • Ensure that claims are not fraudulent
  • Contact claimants’ doctors or employers to get additional information on questionable claims
  • Confer with legal counsel on claims when needed
  • Negotiate settlements
  • Authorize payments

Claims adjusters, appraisers, examiners, and investigators have varying duties, depending on the type of insurance company they work for. They must know a lot about what their company insures. For example, workers in property and casualty insurance must know housing and construction costs to properly evaluate damage from floods or fires. Workers in health insurance must be able to determine which types of treatments are medically necessary and which are questionable. 

Adjusters inspect property damage to determine how much the insurance company should pay for the loss. They might inspect a home, a business, or an automobile.

Adjusters interview the claimant and witnesses, inspect the property, and do additional research, such as look at police reports. They may consult with other workers, such as accountants, architects, construction workers, engineers, lawyers, and physicians, who can offer a more expert evaluation of a claim.

Adjusters gather information—including photographs and statements, either written or recorded on audio or video—and put together a report for claims examiners to evaluate. When the examiner approves the claim, the adjuster negotiates with the policyholder and settles the claim.

If the claimant contests the outcome of the claim or the settlement, adjusters work with attorneys and expert witnesses to defend the insurer’s position.

Some claims adjusters work as self-employed public adjusters. Often, they are hired by claimants who prefer not to rely on the insurance company’s adjuster. The goal of adjusters working for insurance companies is to save as much money for the company as possible. The goal of a public adjuster working for a claimant is to get the highest possible amount paid to the claimant. They are paid a percentage of the settled claim.

Sometimes, self-employed adjusters are hired by insurance companies in place of hiring adjusters as regular employees. In this case, the self-employed adjusters work in the interest of the insurance company.

Appraisers estimate the cost or value of an insured item. Most appraisers who work for insurance companies and independent adjusting firms are auto damage appraisers. They inspect damaged vehicles after an accident and estimate the cost of repairs. This information then goes to the adjuster, who puts the estimated cost of repairs into the settlement.

Claims examiners review claims after they are submitted to ensure claimants and adjusters followed proper guidelines. They may assist adjusters with complicated claims or when, for example, a natural disaster occurs and the volume of claims increases.

Most claims examiners work for life or health insurance companies. Examiners who work for health insurance companies review health-related claims to see whether the costs are reasonable, given the diagnosis. After they review the claim, they authorize appropriate payment, deny the claim, or refer the claim to an investigator.

Examiners who work for life insurance companies review the causes of death and pay particular attention to accidents, because most life insurance companies pay additional benefits if a death is accidental. Examiners also may review new applications for life insurance policies, to make sure that the applicants have no serious illnesses that would make them a high risk to insure.

Insurance investigators handle claims in which the company suspects fraudulent or criminal activity such as arson, staged accidents, or unnecessary medical treatments. The severity of insurance fraud cases varies, from overstated claims of damage to vehicles to complicated fraud rings. Investigators often do surveillance work. For example, in the case of a fraudulent workers’ compensation claim, an investigator may covertly watch the claimant to see if he or she does anything that would be ruled out by injuries stated in the claim.

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How To Become A Medical 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.

Education

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.

Training

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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Medical Claims Examiner Career Paths

Medical Claims Examiner
Billing Specialist Accounts Receivable Specialist
Accounts Receivable Manager
6 Yearsyrs
Account Representative Sales Manager Office Manager
Administrative Manager
6 Yearsyrs
Billing Specialist Accountant Senior Auditor
Audit Manager
6 Yearsyrs
Office Manager Human Resources Coordinator Benefit Specialist
Benefits Manager
8 Yearsyrs
Account Representative Account Executive Office Manager
Business Office Manager
8 Yearsyrs
Service Representative Client Services Manager Client Manager
Client Account Manager
6 Yearsyrs
Medical Claims Processor Billing Specialist Collections Specialist
Collections Manager
5 Yearsyrs
Claim Auditor Specialist Property Manager
Compliance Manager
9 Yearsyrs
Billing Representative Finance Counselor Enrollment Counselor
Enrollment Manager
7 Yearsyrs
Licensed Practical Nurse Nurse Occupational Health Nurse
Health Services Manager
7 Yearsyrs
Claims Analyst Provider Relations Representative
Manager, Provider Relations
9 Yearsyrs
Office Manager Billing Specialist
Medical Billing Manager
6 Yearsyrs
Licensed Practical Nurse Licensed Practical Nurse Staff Nurse Medical Specialist
Medical Supervisor
5 Yearsyrs
Medical Claims Processor Office Manager
Office Manager Of Human Resources
7 Yearsyrs
Claims Analyst Patient Access Representative Service Supervisor
Patient Services Manager
8 Yearsyrs
Claims Adjuster Account Representative Billing Manager
Revenue Manager
8 Yearsyrs
Claim Auditor Claims Supervisor Risk Manager
Risk Management Director
10 Yearsyrs
Senior Claims Examiner Senior Claims Representative Claims Manager
Risk Manager
8 Yearsyrs
Senior Claims Examiner Claim Specialist Claims Analyst
Senior Claims Analyst
6 Yearsyrs
Claims Adjuster Senior Claims Representative Claim Processor
Senior Claims Examiner
7 Yearsyrs
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Average Length of Employment
Claim Auditor 3.4 years
Claims Clerk 3.3 years
Claim Processor 3.2 years
Claims Coordinator 3.1 years
Medical Examiner 3.1 years
Claims Assistant 3.0 years
Claims Analyst 3.0 years
Top Careers Before Medical Claims Examiner
Teller 6.1%
Cashier 3.6%
Internship 2.6%
Top Careers After Medical Claims Examiner
Teller 3.3%
Specialist 3.0%

Do you work as a Medical Claims Examiner?

Medical Claims Examiner Demographics

Gender

Female

82.0%

Male

15.3%

Unknown

2.8%
Ethnicity

White

64.0%

Hispanic or Latino

14.7%

Black or African American

10.9%

Asian

6.8%

Unknown

3.7%
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Foreign Languages Spoken

Spanish

56.3%

Norwegian

12.5%

Portuguese

6.3%

Cayuga

6.3%

Dutch

6.3%

Carrier

6.3%

Hindi

6.3%
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Medical Claims Examiner Education

Schools

University of Phoenix

15.1%

Kaplan University

7.5%

Houston Community College

6.5%

Rasmussen College

6.5%

Temple University

5.4%

Kirkwood Community College

5.4%

Syracuse University

4.3%

Everest Institute

4.3%

Ashford University

4.3%

Marshall University

4.3%

University of Wisconsin - Milwaukee

4.3%

California State University - Northridge

4.3%

Liberty University

4.3%

Richland College

4.3%

University of Alabama

3.2%

West Virginia University Institute of Technology

3.2%

American River College

3.2%

Strayer University

3.2%

Montgomery College

3.2%

Southern Illinois University Carbondale

3.2%
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Majors

Business

25.2%

Health Care Administration

20.0%

Nursing

7.3%

Accounting

6.7%

Medical Assisting Services

5.3%

Insurance

5.0%

Management

3.7%

General Studies

3.2%

Human Resources Management

3.0%

Criminal Justice

2.8%

Psychology

2.3%

Computer Information Systems

2.3%

Computer Science

2.1%

Secretarial And Administrative Science

1.8%

Education

1.6%

Liberal Arts

1.6%

Communication

1.6%

Information Technology

1.6%

Marketing

1.6%

Legal Support Services

1.4%
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Degrees

Other

35.4%

Bachelors

21.2%

Associate

16.8%

Masters

9.7%

Certificate

9.1%

Diploma

5.3%

License

1.4%

Doctorate

0.9%
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Medical Claims Examiner Videos

Dawn Training Centre - Professional Career Courses, Programs and Certificates

Car Accident in NY: Claims Examiner Offers You $$$. Do You Take It?

What's New in Medical Claims Processing?

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Top Skills for A Medical Claims Examiner

  1. Medical Claims Actions
  2. Provider Contracts
  3. Customer Service
You can check out examples of real life uses of top skills on resumes here:
  • Documented medical claims actions by completing forms, reports, logs, and records.
  • Processed claims in accordance with corporate policies and procedures including but not limited to provider contracts, single case agreemen
  • Received client letter of recognition for providing exceptional customer service.
  • Analyzed and investigated medical claims utilizing ICD-9 and CPT-4 coding.
  • Submitted reimbursement claims to insurance companies and government entities.

What is it like to work as a Medical Claims Examiner

5.0

What was your job title?

Medical Claims Examiner.. Show More

What do you like the most about working as Medical Claims Examiner?

I'm gratified by forensics, accounting, mistakes, proceedure and changing codes and law... Show More

What do you NOT like?

That I know I make more money working in many other fields... Show More

How Would You Rate Working As a Medical Claims Examiner?

Are you working as a Medical Claims Examiner? Help us rate Medical Claims Examiner as a Career.

Medical Claims Examiner Videos

Dawn Training Centre - Professional Career Courses, Programs and Certificates

Car Accident in NY: Claims Examiner Offers You $$$. Do You Take It?

What's New in Medical Claims Processing?

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