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Become A Senior Claims Examiner

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Working As A Senior 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

  • $62,980

    Average Salary

What Does A Senior Claims Examiner Do At Healthfirst

* Reviewing and investigating claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst Policy and Procedure.
* Subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
* Identifying defects and improving departmental performance by supporting quality, operational efficiency and production goals.
* Reporting and presenting preliminary findings based on trending and interpretation.
* Trending and comparing analyses against departmental and corporate standards.
* Assist with developing and participating in effective training and documentation.
* Soliciting and coordinating required information between Management staff and team members to complete daily assignments.
* Examining and Processing of Claims.
* Working on multiple audits, appeals or other ad hoc projects.
* Additional duties as assigned

What Does A Senior Claims Examiner Do At Metlife

* Interviews insureds, claimants and other parties to determine the facts of the claim.
* Creates and documents claims file to comply with company guidelines and state regulations.
* Reviews factual information to determine coverage and/or liability of all parties to the claim.
* Determines value of the claim considering depreciation and actual cash value, negotiates and commits to the settlement, and moves claim to closure.
* Resolves complaints, and participates in arbitration and/or grievance procedures.
* Recommends subrogation and/or SIU referral.
* Manages pending claims to meet company quality criteria.
* Performs other related duties as assigned or required

What Does A Senior Claims Examiner Do At Unitedhealth Group

* Coordinates with the Claims Manager and / or Claims Supervisor on workflow issues and the handling of batches in date order Documents all claims production via the system BA screen (which tracks individual examiner production).
* Online transactions to be tracked separately Responsible for weekly / monthly goal of batches to include meeting and maintaining a 95% quality standard and production standard of 35 claims per hour on transactions Evaluates each claim for appropriate coding of CPT and ICD codes against charges that are being billed and entered Responsible for inputting accurate batch accounts, invoice numbers, status codes to ensure accurate entry into Claims Processing system, which creates reporting Must meet and maintain 95% quality expectations

What Does A Senior Claims Examiner Do At Combined Insurance

* Responsible for conducting/managing factual claims investigation, including communications with policyholders, remediation experts, counsel and others to gather all claim facts.
* Analyze contracts, policies and applicable law to determine appropriate coverage position
* Negotiate cost sharing agreements with carriers/policyholders
* Assign defense counsel, manage litigation strategy and budgets
* Evaluate claims and give management presentations on proposed values and disposition plans
* Maintain physical/electronic file, comply with all policies and procedures, as directed;
* Respond to internal requests for information from management, reinsurers, etc.;
* Prepare timely and accurate management reporting

What Does A Senior Claims Examiner Do At Combined Insurance

* Analyze first report to determine nature of loss, coverage provided and scope of injury/damage in personal and commercial auto and general liability cases.
* Conduct investigations of all aspects of reported claims including potential fraud.
* Secure all appropriate supporting documentation and verify same for accuracy, relationship and completeness.
* Apply knowledge of jurisdictional regulations and case law in all territories handled.
* Effectively negotiate liability and damages where appropriate.
* Demonstrated ability to effectively manage and monitor cases to achieve timely development and disposition of inventory
* KNOWLEDGE

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How To Become A Senior 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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Senior Claims Examiner jobs

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Senior Claims Examiner Career Paths

Senior Claims Examiner
Claim Specialist Account Manager Billing Specialist
Accounts Receivable Manager
6 Yearsyrs
Claims Supervisor Office Manager Business Office Manager
Business Office Director
8 Yearsyrs
Claim Specialist Billing Specialist
Business Office Manager
8 Yearsyrs
Billing Specialist Specialist Case Manager
Career Manager
6 Yearsyrs
Benefit Specialist Claims Representative Adjuster
Casualty Claims Supervisor
9 Yearsyrs
Claims Supervisor Claims Manager
Claims Director
12 Yearsyrs
Senior Claims Representative Claims Supervisor
Claims Manager
8 Yearsyrs
Accounts Receivable Specialist Accounting Coordinator Account Associate
Client Account Manager
6 Yearsyrs
Billing Specialist Collector
Collections Manager
5 Yearsyrs
Senior Claims Specialist Claims Supervisor Claims Manager
General Adjuster
11 Yearsyrs
Service Representative Registered Nurse Occupational Health Nurse
Health Services Manager
7 Yearsyrs
Litigation Support Specialist Adjuster Loss Mitigation Specialist
Loss Control Manager
6 Yearsyrs
Benefit Specialist Enrollment Specialist Provider Services Representative
Manager, Provider Relations
9 Yearsyrs
Claims Manager Human Resources Manager Practice Manager
Patient Services Manager
8 Yearsyrs
Account Manager Underwriter Insurance Specialist
Reimbursement Analyst
6 Yearsyrs
Senior Claims Specialist Claims Manager General Adjuster
Senior Claims Adjuster
7 Yearsyrs
Service Representative Claims Representative Claims Analyst
Senior Claims Analyst
6 Yearsyrs
Senior Claims Analyst Billing Specialist Claims Representative
Senior Claims Representative
6 Yearsyrs
Senior Claims Representative Claim Specialist
Senior Claims Specialist
7 Yearsyrs
Claims Manager Operations Manager Underwriter
Underwriting Consultant
10 Yearsyrs
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Senior Claims Examiner Demographics

Gender

  • Female

    68.2%
  • Male

    29.8%
  • Unknown

    2.0%

Ethnicity

  • White

    83.5%
  • Hispanic or Latino

    8.5%
  • Asian

    6.0%
  • Unknown

    1.5%
  • Black or African American

    0.4%
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Languages Spoken

  • Spanish

    57.1%
  • Carrier

    14.3%
  • Portuguese

    3.6%
  • Bosnian

    3.6%
  • Serbian

    3.6%
  • French

    3.6%
  • Armenian

    3.6%
  • Tagalog

    3.6%
  • Dakota

    3.6%
  • Croatian

    3.6%
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Senior Claims Examiner

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Senior Claims Examiner

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Top Skills for A Senior Claims Examiner

CustomerServiceClaimsExaminerMedicalProvidersMedicalTreatmentDisabilityClaimsMedicalClaimsBodilyInjuryClaimsComplianceMedicaidProcessClaimsGeneralLiabilityClaimsAutoMedicalRecordsIndependentAdjustersComplexClaimsCPTInsuranceClaimsDentalClaimsDataEntryAdjudicateClaims

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Top Senior Claims Examiner Skills

  1. Customer Service
  2. Claims Examiner
  3. Medical Providers
You can check out examples of real life uses of top skills on resumes here:
  • Developed superior communication and customer service skills through consistent interaction with a variety of internal and external contacts.
  • Answered phone calls and processed 150+ claims per day as Senior Claims Examiner, consistently exceeding daily/weekly/monthly goals.
  • Communicated with injured workers, employers, attorneys, vendors and medical providers.
  • Discussed appropriateness of medical treatment with medical case managers.
  • Adjudicated disability claims based on information from customers and medical documents/records.

Top Senior Claims Examiner Employers